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Columbia  (HnitJeraitp 
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College  of  ^Jjpstctans;  anb  burgeons 


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rSTra 


Digitized  by  the  Internet  Archive 

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http://www.archive.org/details/systemofobstetriOOauva 


A  SYSTEM  OF 


OBSTETRICS 


WITH   FIVE   HUNDRED    AND    THIRTY-SEVEN    ILLUSTRATIONS; 
BASED  UPON  A  TRANSLATION  FROM  THE  FRENCH 

OF   AWARD 


REVISED    BY 

CURTIS  M.  BEEBE,  M.  D. 

CHICAGO.  ILL. 


1892 
J.  B.  FLINT  &  COMPANY 

NEW   YORK 


Ou 


Copyright, 

1892, 

J.  BENTON   FLINT. 


hWUfrtT  ft  f ««B?Mah 


mEStVBSt 


THE   MERSHON   COMPANY   PRESS, 
RAHWAV,   N.   J. 


CONTENTS. 


PAGE. 

I.  Menstruation  and  Fecundation, 17 

II.  Development  and  Description  of  the  Human  ovum.    .  27 

III.  Modification  of  the  Maternal  Organism.  .        .  64 

IV.  The  Parturient  Canal 84 

V.  Presentations  and  Positions.         ...        .        .        .  97 

VI.  Symptomatology  of  Pregnancy, 127 

VII.  The  Diagnosis  of  Pregnancy 158 

VIII.  Progress  and  Duration  of  Pregnancy. — Prognosis.— 

Hygiene, 164 

IX.  Accouchement.— Maternal  Phenomena.  .   .   .   170 

Phenomena  of  the  Appendages 188 

X.  Mechanism  of  Accouchejient.— Fetal  Phenomena.  .   194 
XI.  Influence  of  Accouchement  on  the  Mother  and  on 

the  Child, 214 

XII.  Management  of  the  Accouchement 224 

XIII.  Accouchement.— Delivery  of  the  Appendages,         .      234 

XIV.  Post-Partum, 240 

XV.  Puerperal  Pathology. — General  Disease. — Eclampsia.  250 

XVI.  Puerperal  Septicemia, 257 

XVII.  Puerperal   Pathology.  —  Extra    Genital    Localized 

Diseases. 269 

XVIII.  Diseases  of  the  Bony  Pelvis 277 

XIX.  Diseases  of  the  Genital  System  and  its  Dependen- 
cies.—Genital  Dystocia. 307 

XX.  Diseases  and  Anomalies  of  the  Placenta.         .        .      324 

XXI.  Diseases  of  the  Ovuline  Envelopes,       ....  335 

XXII.  Diseases  and  Death  of  the  Fetus.— Fetal  Dystocia,  338 

XXIII.  Multiple  Pregnancy, 348 

XXIV.  Premature  Expulsion 359 

XXV.  Accidents  of  Accouchement, 368 

XXVI.  Accidents  of  the  Delivery  of  Appendages.  .        .  376 

XXVII.  Accidents  of  Post-Partum. 389 

XXVIII.  The  Vectis  or  the  Lever 391 

XXIX.  Versions 302 

XXX.  Forceps 402 

XXXI.  Manual  Extraction, 416 

XXXII.  Induced  Expulsion, 420 

XXXIII.  Embryotomy 423 

XXXIV.  Hysterotomy. — Cesariax  Section 432 


TREATISE  ON  OBSTETRICS. 


CHAPTER  I. 


MENSTRUATION   AND   FECUNDATION. 

Woman's  life  is  divided  into  three  great  periods :  one,  prsegenital ; 
another,  genital;  the  third,  post-genital.  The  first  extends  from 
birth  to  the  first  menstruation ;  the  second,  from  puberty  to  the 
menopause,  and  the  last,  from  the  menopause  to  the  close  of  life. 

Only  the  genital  period  interests  the  obstetrician,  for  it  is  that 
portion  of  woman's  life  that  is  consecrated  to  procreation.  In  im- 
posing this  role  upon  woman,  nature  has  established  in  her  a  pre- 
ponderance of  the  genital  system,  an  idea  that  Michelet  has  so  well 
expressed  in  the  words,  "Woman  is  a  matrix  supplied  with  organs." 

This  genital  system,  which  dominates  the  feminine  organism, 
imposes  three  different  states,  that  successively  divide  the  genital 
period.  For  a  time  there  is  repose,  calm,  an  intermittent  and  a 
regular  truce  accorded  to  the  economy.  Then  there  is  the  prepa- 
ration for  fecundation,  the  period  of  emission  of  the  ovule,  the 
menstrual  state.  Sometimes,  finally,  after  the  meeting  and  the 
union  of  the  two  elements,  male  and  female,  a  being  developes  in 
the  interior  of  the  uterus,  and  causes  in  the  gestating  woman  a 
series  of  changes  necessary  to  ensure  this  new  life ;  this  epoch  is 
designated  as  the  puerperal  state.  Thus,  a  state  of  repose,  a  men- 
strual state  and  a  puerperal  state  occur  during  the  genital  life  of 
woman.  It  is  the  puerperal  state  that  especially  interests  the 
obstetrician.  Obstetrics  is  the  study  of  the  puerperal  state,  pro- 
vided this  term  is  used  to  designate  the  period  which  extends  from 
impregnation  to  the  end  of  lactation,  or  to  the  end  of  the  third 
month  after  delivery  when  the  mother  does  not  nurse  her  child. 

Before  entering  upon  the  study  of  pregnancy  it  will  be  necessary 
to  consider  briefly  menstruation  and  fecundation,  which  are  its  pre- 
liminaries to  pregnancy.  The  term  menstruation  is  applied  to  the 
flow  of  blood,  which  occurs  periodically  from  the  female  genital 
organs.  Menstruation  comprises  two  essential  phenomena,  ovu- 
lation and  a  sanguineous  flow.     Each  demands  a  special  study. 

Ovulation  is  the  liberation  by  the  ovary  of  a  cell,  having  an 
important  future  and  to  which  has  been  given  the  name  ovule. 


18 


Menstruation  and  Fecundation. 


A  word  on  the  ovary  and  its  contents.  The  ovary,  situated  in 
the  posterior  wing  of  the  broad  ligament,  is  a  small  gland  resembling 
an  almond  in  form.  It  measures  four  centimetres  in  length,  two  in 
height  ami  one  centimetre  and  a  half  in  its  antero-posterior  thick- 
no-  :  it-  weight  is  eight  grammes.  Its  two  surfaces  and  its 
superior  border  being  free  it  floats  in  the  peritoneal  cavity.  Its 
inferior  border  is  attached  by  a  ligament  to  the  uterus  and  to  the 
pavilion  of  the  tube  by  one  of  its  fimbriae.  I  shall  return  to  the 
anatomical  relations  of  the  ovary  in  connection  with  the  subject  of 
fecundation. 


r^'^P^^1^^^, 


FlG.  i. — Section  of  a  fragment  of  the  cvary.  S  S,  ovarian  stroma:  e,  epithelium ; 
I  I,  Graafian  follicles  highly  developed ;  2  2,  non-developed  follicles;  3,  very  small 
follicles;  O,  ovule  in  the  Graafian  follicle;  vv,  bloodvessels;  9,  cells  of  the  granular 
membrane. 

On  section,  the  structure  of  the  ovary  is  found  of  a  reddish  color, 
rose  colored  in  some  parts,  a  deeper  red  in  others.  This  is  the 
bulbus  portion,  a  mixture  of  non-striated  mucular  fibres,  con- 
nective  tissue  fibres,  arteries,  veins,  lymphatics  and  some  nerve 
filaments.  This  bulbus  portion  forms  almost  the  whole  of  the 
ovary.  It  is  covered  by  a  thin  envelope,  which  scarcely  measures 
a  millimetre  in  thickness. 

The  peripheral  portion,  called  the  fibrous  tunic  by  the  older 
writers,  is  distinguished  from  the  subjacent  portion  by  its  pale 
color,  its  apparent  homogeneousness  and  by  its  firmness.  This 
envelope  is  the  fundamental  portion  of  the  ovary.  It  is  formed  by 
the  accumulation  "f  <>\  i-;t  <•.-.,  also  called  ovarian  vesicles  or  Graafian 
follicles.    It  i-  in  the  interior  of  these  vesicles  that  the  ovule  is  found. 

I  lontrary  to  what  is  observed  in  all  the  other  glands  of  the  organ- 
i-m,  the  ovary  has  its  cavity  at  the  surface  and  it  is  there  that  the 
phenomenon  of  ovulation  takes  place.  To  comprehend  the  phe- 
nomenon a  complete  description  of  the  ovisac  and  its  contents  is 


Menstruation  and  Fecundation. 


19 


indispensable.  The  follicle  contains  an  accumulation  of  other  cells, 
among  them  one  of  particular  character,  the  ovule.  The  ovule  is 
the  female  primordial  element,  just  as  the  spermatozoid  is  the  pri- 
mordial element  of  the  male.  The  ovule  is  constituted  by  the 
germinative  spot,  the  germinative  vesicle,  the  vitellus  and  vitelline 
membrane.  The  ovule  is  contained  in  the  interior  of  the  ovarian 
vesicle  surrounded  by  cells,  the  whole  being  enveloped  in  a  common 
membrane.  Altogether  these  structures  form  the  ovisac.  In  its 
conformation  the  ovule  does  not  differ  from  ordinary  cells.  Each 
ovisac  contains  an  ovule,  and  each  ovary  contains,  as  M.  Sappey 
has  demonstrated,  approximately  300,000  ovisac,  or  600,000  to  each 
woman. 


Fig.  2. — Schematic  representation  of  the  Graafian  follicle  or  ovisac 
and  of  its  contents,  the  ovule. 

Let  us  follow  an  ovisac  in  its  menstrual  evolution.  In  its  interior 
the  cells  assume  proliferation  and  at  one  point  a  cavity  is  formed, 
that  fills  with  liquid,  perhaps  the  result  of  the  cellular  activity. 
The  vesicle  enlarges  markedly  under  the  influence  of  the  cell  pro- 
liferation and  of  the  accumulation  of  liquid.  It  takes  on  a  size 
that  becomes  visible  to  the  naked  eye  at  the  surface  of  the  ovary. 


20 


Menstruation  and  Fecundation. 


This  swelling  continues  and  the  vesicle,  instead  of  remaining 
spherical,  takes  an  ovular  form,  with  the  small  extremity  corre- 
sponding to  the  free  surface  of  the  ovary.  At  the  moment  when 
the  distention  hecomes  too  great,  rupture  occurs  at  the  most  pro- 
jecting point.  This  rupture,  prepared  for  by  the  modifications  in 
the  ovisac,  is  provoked  by  the  congestion  of  the  bulbus  portion  of 
the  ovary.  This  congestion  occurs  under  the  influence  of  menstru- 
ation or  any  genital  excitation,  such  as  that  produced  by  coitus. 


Fig.  3. — Ovisac  preparing  to  rupture  and  liberate  the  ovule. 

At  the  moment  of  dehiscence  the  ovule  is  thrown  outward. 
The  ovisac,  abandoned  by  the  ovary,  becomes  henceforth  useless. 
Its  role  is  completed.  Blood  and  plastic  lymph  are  effused  into  its 
interior.  The  place  of  rupture  which  has  given  passage  to  the 
ovule  cicatrizes.  The  vesicle  becomes  folded  on  itself.  From  the 
transformations  of  its  contents  it  takes  on  the  appearance  of  the 
corpus  liitcinn,  disappearing  by  degrees  until  reduced  to  a  linear  or 
radiate  cicatrix  that  is  more  or  less  depressed.  The  corpus  luteum 
of  menstruation  differs  from  that  of  pregnancy  only  by  the  fact 
that  the  iatter,  under  the  influence  of  the  activity  impressed  on  all 
the  genital  zone  by  fecundation,  instead  of  diminishing,  enlarges 
for  two  or  three  months  and  does  not  undergo  regression  until  after 
delivery.     Thus  we  understand  the  phenomena  of  ovulation,  there 


Menstruation  and  Fecundation.  21 

now  remains  to  be  studied  the  other  condition  of  menstruation,  that 
is,  the  flow  of  blood. 

The  periodical  hemorrhage  that  occurs  during  the  genital  life  of 
woman  generally  begins,  in  France,  at   fifteen  years  of  wj^  and 

inates  at  forty-live.     Thus  it  may  be  said  that  the  genital  life 
continues  about  thirty  years.     But  there  are  observed  frequent 

variations  in  the  period  of  appearance  and  of  cessation  of  the 
menses,  variations  which  depend  upon  the  constitution,  upon  the 
temperament,  upon  the  geographical  latitude  of  the  country,  upon 
the  education,  upon  the  habitual  diet,  upon  the  race  and  upon  the 
social  condition  of  the  woman.  Various  facts  of  precocious  and  of 
late  menstruation  have  been  cited.  The  menstrual  flow  is  repro- 
duced in  general  every  solar  month  (thirty  to  thirty-one  days), 
sometimes  oftener ;  every  lunar  month  (twenty-eight  days),  and 
some  women  menstruate  even  every  three  weeks,  others  only  every 
five  weeks.  Finally,  there  are  some  in  whom  the  appearance  of  the 
flow  is  capricious  and  irregular.  The  duration  of  the  flow  is  com- 
monly from  three  to  six  days.  Some  women  only  menstruate  a  few 
hours,  others  from  ten  to  twelve  days.  I  only  give  the  extreme 
figures.  It  is  difficult  to  appreciate  the  quantity  of  blood  lost  at  each 
menstrual  period,  but  a  quantity  less  than  fifty  grammes  or  greater 
than  five  hundred  grammes  may  be  considered  as  pathological. 

The  blood  which  flows  during  the  menstrual  period  has  its  source 
in  the  tubes  and  in  the  body  of  the  uterus,  rarely  in  some  other 
portion  of  the  genital  organs.  Exceptionally  the  flow  may  occur 
from  another  region,  in  such  cases  as  have  been  called  menstrual 
deviation,  where  the  periodical  haemorrhage  takes  place  from  the 
lungs,  from  the  intestine,  from  the  mouth,  from  the  nose,  from  the 
surface  of  a  wound,  from  an  erectile  tumor  or  from  the  nipple. 

I  return  to  the  uterus.  At  each  menstruation  the  uterine  mucosa 
is  folded  on  itself  in  such  a  way  as  to  recall  the  cerebral  convolutions. 
This  tumefaction,  the  consequence  of  the  genital  congestion,  favors 
the  implantation  of  the  fecundated  ovule,  which  thus  becomes 
grafted  on  the  folds  of  the  mucosa.  The  mucosa  also  undergoes 
other  modifications,  about  which  there  are  so  many  different 
opinions  that  it  is  impossible  to  judge  of  their  true  nature. 

Having  sufficiently  discussed  the  two  essential  phenomena  of 
menstruation,  there  remains  the  study  of  their  relations.  Does  the 
flow  of  blood  depend  upon  ovulation?  Or,  on  the  contrary,  does 
ovulation  depend  upon  the  blood-flow?  Or,  a  third  hypothesis,  are 
these  two  factors  independent  ?  Each  of  these  theories  has  its 
partisans.  Without  wishing  to  enter  here  into  a  complete  discussion 
of  this  difficult  question,  I  shall  say  that  I  believe  in  a  certain  de-  ' 
gree  of  independence  of  ovulation  and  menstruation.  I  also  believe  ' 
that  they  are  subordinate,  one  to  the  other,  in  such  a  way  that  they 
most  often  occur  together.      It  is  the  union  of  ovulation  and  of 


22  Menstruation  and  Fecundation. 

istruation  that  constitutes  menstruation,  as  the  current  of  air 
and  the  contraction  of  the  vocal  cords  forms  the  voice.  Now  there 
is  the  same  union  and  the  same  independence  existing  between  the 
current  of  air  and  the  contraction  of  the  vocal  cords,  as  between 
ovulation  and  the  ilow  of  blood.  Ovulation  is  the  essential  phe- 
nomenon of  menstruation  and  the  sanguineous  flow  the  accessory 
element.  One  assures  fecundation,  the  other  preparation  for  it. 
Their  union  place  the  woman  in  the  most  favorable  condition  for 
conception.  From  this  study  of  menstruation  we  pass  to  that  of 
fecundation  or  conception. 

Fecundation  is  the  union  of  two  elements,  male  and  female,  in 
the  aim  of  procreation  of  a  new  being.  Conception  is  the  synonym 
of  fecundation,  and  only  differs  from  it  by  a  simple  shade  of 
meaning;  fecundation  indicating  the  union  of  the  two  procreative 
elements,  and  conception  applying  better  to  the  state  of  the  woman 
who  has  just  been  fecundated.  We  have  spoken  of  one  element, 
the  ovule.     We  shall  now  turn  to  the  spermatozoid. 

The  spermatozoid,  wrongly  called  spermatozoon  at  the  time  it 
was  considered  animalcule,  is  composed  of  a  head  of  ovular  form, 
measuring  5  mm.  in  its  long  axis,  of  a  small  cylindrical  body  of- 
fering almost  the  same  length,  and  finally  an  undulating  tail  which 
grows  successively  thinner  toward  its  extremity,  and  has  a  length 
of  45  mm.  From  the  recent  studies  on  the  development  and 
the  nature  of  the  spermatozoid,  it  has  been  proven  that  it  is  only 
a  cell  of  a  particular  form,  the  nucleus  being  represented  by  the 
head  and  the  protoplasm  by  the  intermediate  segment.  The  tail  is 
only  a  simple  cilium  analogous  to  that  met  in  other  cells  of  the 
economy.  Under  the  microscope,  in  a  drop  of  fresh  spermatic  fluid, 
spermatozoids  are  seen  in  great  number,  moving  with  great  rapidity. 
These  displacements  are  due  to  a  corkscrew  movement  of  the  cilium 
which  constitutes  the  tail  of  the  anatomical  element.  In  a  second 
a  spermatozoid  covers  its  length ;  it  moves  at  the  rate  of  two  to 
three  millimetres  a  minute.  These  movements  quickly  cease  as 
soon  as  the  spermatozoid  is  placed  in  an  acid  medium  instead  of 
tin-  alkaline  fluid  in  which  it  normally  occurs.  The  uterine  fluid 
being  alkaline,  and  likewise  that  of  the  tube,  the  spermatozoid  pre- 
serves  its  n.ovements  therein  for  a  certain  length  of  time,  to  fifteen 
days,  according  to  Schroeder,  and  perhaps  even  more.  But  if  there 
is  endometritis,  the  uterine  secretion  becomes  acid  and  the  sperma- 
tozoid is  quickly  killed. 

The  two  elements,  male  and  female,  now  being  understood,  we 
may  essay  the  solution  of  the  problem  of  fecundation,  and  to  this 
end  we  shall  note  successively  :  The  place  of  the  meeting  of  these 
two  elements;  the  approach  of  these  elements,  one  toward  the 
other ;  the  difficulties  that  they  must  overcome  before  union. 


Menstruation  and  Fecundation. 


28 


At  the  moment  of  ovular  dehiscence  tin*  ovule  becomes  free  at 
the  surface  of  the  ovary,  the  spermatozoid,  for  the  other  part,  ia  de- 
posited at  the  external  orifice  of  the  uterus  as  a  consequence  of 
coitus.  To  meet,  the  ovule  and  the  spermatozoid  must  travel 
through  the  uterus  and  the  tube.  But  the  approach  of  these  elements 
toward  each  other  can  only  he  comprehended  by  a  previous  study 
of  the  parts  through  which  they  must  pass.  We  turn,  then,  to  the 
cavities  of  the  uterus  and  of  the  tubes. 


Head. 


Intermediate 
Segment. 


.Tail. 


Fig.  4. — Spermatozoid. 


Fig.  5.  —  Uterus: 
body;  isthmus;  cer- 


The  uterine  cavity  is  subdivided  into  that  of  the  body  and  that  of 
the  cervix,  which  are  separated  by  a  short  canal,  the  isthmus  (Fig. 
5).  Each  of  these  cavities  measure  about  two  and  one-half  cen- 
timetres vertically,  though  in  the  nulliparous  woman  the  cavity  of 
the  cervix  exceeds  that  of  the  body,  and,  on  the  contrary,  in  the 
muciparous  woman  that  of  the  body  is  relatively  greater.  The 
cavity  of  the  body  has  a  triangular  aspect,  the  superior  angles  being 
continuous  with  the  tubes,  and  the  inferior  with  the  isthmus.  The 
surfaces  are  plane  and  applied  one  to  the  other  in  such  a  way  that 
the  space  is  virtual  or  is  filled  in  the  normal  state  with  a  small 
quantity  of  mucus. 

The  cavity  of  the  cervix  is  fusiform,  slightly  flattened  from  before 
backward.  The  mucosa  that  lines  its  walls  is  uplifted  by  the 
arbor  vita,  two  in  number.  Each  one  of  these  structures  is  composed 
of  a  longitudinal  axis,  from  which  arise  transverve  and  ascending 
branches.  The  anterior  axis  begins  at  the  external  orifice  and  is 
directed  obliquely  above  and  to  the  right ;  the  posterior  axis,  placed 
symmetrically  to  the  origin  of  the  former,  followes  an  oblique  path 
in  an  analogous  direction,  that  is  to  the  left  and  toward  the  internal 
orifice.     The  two  axes  terminate  by  gradual  diminution  toward 


24  Menstruation  and  Fecundation. 

the  isthmus,  no  branches  existing  at  that  place.  The  utility  of  the 
arbor  vita'  is  unknown,  but  it  is  supposed  that  they  favor  the  passage 
of  the  spermatozoids. 

The  uterine  cavity  is  lined  by  a  mucosa,  of  one  to  two  millimetres 
in  thickness,  continuous  above  with  that  of  the  tube  and  below  with 
that  of  the  cervix.  In  the  cervical  cavity  the  epithelium  is  calci- 
form,  and  is  continued  into  the  interior  of  the  numerous  racemose 
glands  of  this  region.  At  the  summit  of  the  projections  of  the 
arbor  vitae  the  epithelium  becomes  cylindrical  and  possesses  cilia. 
In  the  isthmus  and  in  the  cavity  of  the  body  of  the  uterus,  there  is 
found  cylindrical  epithelium  writh  cilia,  that  is  prolonged  into  the 
interior  of  the  tubular  glands  (with  the  exclusion  of  the  cilia),  the 
only  variety  contained  in  this  region. 

The  tube  or  oviduct  is  the  canal  that  establishes  communication 
between  the  surface  of  the  ovary  and  the  uterine  cavity.  When  the 
abdominal  cavity  is  opened,  and  the  intestines  are  removed,  there 
will  be  seen  on  each  side  of  the  uterus  two  transverse  folds.  These 
are  the  broad  ligaments,  the  free  or  the  superior  border  of  which  is 
divided  into  three  wings.  The  anterior  contains  the  round  ligament, 
the  median  contains  the  tube,  and  the  posterior  is  reserved  for  the 
ovary  and  its  ligaments,  to  the  number  of  two,  one  attaching  it  to  the 
uterus  (ligament  of  the  ovary),  the  other  to  the  tube  (ligament  of 
the  tube). 

The  tube  presents  an  average  length  of  twelve  centimetres.  De- 
parting from  the  supero-lateral  angle  of  the  uterus  it  takes  a  slightly 
tortuous  course  toward  the  lateral  wall  of  the  pelvis,  terminating  a 
short  distance  from  this  wall  by  expanding  into  a  fringed  and 
mobile  pavilion.  In  the  vicinity  of  the  uterus  the  diameter  of  the 
tube  is  about  one  millimetre,  and  this  increases  more  and  more 
toward  the  pavilion.  Its  structure  comprises  a  superficial,  incom- 
plete, serous  envelope ;  a  non-striated  muscular  tunic,  composed  of 
a  superficial  longitudinal  layer  and  a  deep  circular;  finally,  the 
mucosa,  which  presents  numerous  longitudinal  folds  (Fig.  6).  The 
epithelium  which  lines  its  cavity  has  cilia,  as  in  the  uterus,  and 
at  the  free  border  of  the  tube  it  becomes  directly  continuous  with 
the  flattened  epithelium  of  the  peritonaeum.  This  description  is 
sufficient  to  give  us  a  succinct  idea  of  the  canal,  which  extends  from 
the  ovary  to  the  external  orifice  of  the  uterus,  and  which  the  two 
elements,  male  and  female,  follow  in  their  approach  toward  each 
other. 

But  a  preliminary  question  occurs  here,  that  of  knowing  at  what 
place  the  meeting  of  the  spermatozoid  and  ovule  usually  takesplace. 
If  it  is  possible  to  determine  this  point,  we  know  in  advance  the 
path  taken  by  each  of  these  elements.  It  has  been  shown  from  the 
experiments  of  Bisehoff  and  of  Nuck,  on  bitches,  that  the  meeting 
-  place  in  the  external  third  of  the  tube.     Coste  admits  the  same 


Menstruation  and  Fecundation.  l~> 

for  the  human  female;  he  also  believes  thai  if  the  meeting  takes 
place  aearer  the  uterus  fecundation  i-  nol  possible,  for  is  pene- 
trating thus  far  the  ovule  becomes  bo  coated  with  albumen  as  to 
become  impermeable. 

Lei  us  take  the  ovule  at  the  Burface  of  the  ovary  and  the  Bperma- 
tozoid  at  the  entrance  of  the  uterus,  and  follow  these  elements  to 
tht'  point  of  meeting,  in  the  external  third  of  the  tube,  studying 
their  mode  of  progression. 

We  havefour  theories  :  One,  of  the  progression  of  the  spermatozoid 
by  capillary  action  (Coste,  hoiegeois)  ;  on<  ,  as  to  the  action  of  the 
vibratile  cilia  (Muller) ;  another,  as  to  the  movement  of  aspiration 
made  hy  the  uterus  at  the  end  of  coition  (Biolan,  Morgan),  and  a 
fourth,  a  supposition  that  the  sperrnatozoids  are  capable  of  inde- 
pendent migration  by  virtue  of  the  rapid  progression  revealed 
under  the  microscope.  Thus  we  are  in  the  presence  of  four  theories 
that  render  quite  plain  the  progress  of  the  spermatozoid.  It  has 
been  objected  that  ciliated  cells  do  not  exist  in  the  whole  extent  of 
the  genital  organs  ;  that  aspiration  cannot  be  exerted  in  a  cancerous 
uterus ;  that  in  certain  animals  fecundation  is  possible  although 
the  sperrnatozoids  are  not  mobile.  These  are  simple  objections  of 
detail  which  show  us  that  one  of  these  causes  may  be  deficient  or 
absent  without  impeding  fecundation.  It  appears  rational  to  admit 
that  capillary  action,  the  vibratile  cilia,  uterine  aspiration  and 
the  movements  of  the  sperrnatozoids  are  conjoined  in  aiding  the 
progress  of  the  male  element  in  the  interior  of  the  female  genital 
organs.  All  these  theories  are  true  in  part,  but  no  one  of  them 
should  be  admitted  to  the  exclusion  of  the  rest. 

"With  regard  to  the  ovule,  the  problem  to  be  solved  is  the  manner 
in  which  it  passes  from  the  surface  of  the  ovary  to  the  external 
third  of  the  tube.  The  distance  is  short  and  yet  the  difficulty  is 
great,  for  the  route  is  not  continuous.  The  surface  of  the  ovary, 
like  the  pavilion  of  the  tube,  floats  in  the  great  peritoneal  cavity. 
The  ovule  then  passes  from  one  to  the  other,  much  as  a  projectile 
is  thrown  from  one  point  to  another  in  the  atmosphere.  Attempts 
have  been  made  to  explain  this  migration  in  five  different  way- : 

1.  Heller  and  Rouget  believe  that,  at  the  moment  of  dehiscence  of 
an  ovisac,  the  pavilion  of  the  tube,  free  in  the  usual  state,  applies 
itself  on  the  ovary  and  exactly  encloses  it.  The  ovule  is  thus  en- 
grossed and  gathered  into  the  tube  at  its  issue  from  the  ovisac. 

2.  Kehrer  advances  the  theory  of  the  projection  of  the  ovule  into 
the  pavilion  of  the  tube  by  an  impulse  given  it  from  the  bursting 
of  the  Graaffian  follicle.     I  do  not  believe  in  this  fantastic  theory. 

3.  The  ligament  which  unites  the  ovary  to  the  pavilion  is  slightly 
hollowed  out  on  its  upper  surface  in  the  form  of  a  trough ;  Henle 
interprets  this  anatomical  disposition  by  giving  us  the  opinion  that 
the  ovule  follows  tins  from  the  ovary  to  the  tube.     4.  But    little 


26 


Menstruation  and  Fecundation. 


satisfied  with  the  explanations  given,  and  discouraged  in  his  vain 
researches,  Kiwisch  has  advanced  the  idea  that  the  migration  of 
the  ovale  is  accidental.  The  peritonaeum  thus  becomes  the  tomb 
of  useless  ovules.  5.  I  arrive  at  the  theory  of  the  menstrual  lake, 
that  I  have  reserved  for  the  end,  as  it  appears  the  most  adapted  to 
explain  the  migration  of  the  ovule. 


Fig.  6.— Uterus.     Tube.     Ovary. 


Fig.  7. — Posterior  round  ligament.      I,  ligament  of  the  ovary;   2,  ligament  of  the 
tube;  3,  posterior  round  ligament,  with  the  three  branches  external,  median,  internal. 

According  to  Becker,  at  the  moment  of  dehicence  there  occurs 
around  the  ovary  an  accumulation- of  serum  and  liquid  blood  which 
constitutes  a  veritable  lake.  When  the  ovule  leaves  the  ovisac  it 
floats  on  this  fluid,  which,  being  diverted  by  the  tube  into  the  uterus 
draws  the  ovaule  with  it  into  the  genital  canal.  But  an  objection 
arises  at  once.  If  this  current  draws  the  ovule  from  the  ovary 
toward  the  vulva,  how  can  the  spermatozoid,  placed  under  the  same 
influence,  pursue  a  contrary  direction?  1  shall  remark  that  the 
spermatozoid  is  generally  deposited  in  the  feminine  genital  organs 
before  or  after  the  flow,  and  that  it  gains  the  external  third  of  the 
tube  without  undergoing  the  influence  of  this  current.     I  know  that 


Development  and  Description  of  the  Hit/man  Ovum. 


■>- 


some  conceptions  only  take  place  od  condition  of  a  coitus  during 
the  menstrual  period.    J  jut  id  options  may  be  explained  by 

admitting  that  the  spermatic  fluid,  from  it-  special  consistence, 
remains  adherent  to  the  uterine  mucosa,  or  even  to  the  vaginal,  and 
that  it  accomplishes  fecundation  after  cessation  of  the  menstrual 
flow.  We  might  also  suppose  that  by  the  action  of  the  vibratile 
cilia  and  the  movements  of  the  spermatozoids,  the  mule  element  is 
capable  of  overcoming  the  sero-sanguineous  current  to  arrive  at  the 
ovule. 

The  ovule  and  the  spermatozoid  having  met  in  the  external  third 
of  the  tube,  fecundation  occurs,  the  woman  has  conceived  and 
pregnancy  commences.  "We  are  now  to  study  all  the  transforma- 
tions of  this  fecundated  ovule,  which  becomes  the  embryo,  and  then 
the  foetus,  and  all  the  modifications  affecting  the  material  organism 
under  this  influence. 


CHAPTER  II. 


DEVELOPMENT   AND   DESCRIPTION   OF    THE 
HUMAN   OVUM. 

The  fecundated  ovule  in  the  external  third  of  the  tube  continues 
in  its  course  toward  the  cavity  of  the  body  of  the  uterus,  where  it 
arrives  in  a  few  days,  and  where  it  becomes  fixed  and  develops 
during  the  nine  months  of  pregnancy.  During  this  passage  the 
ovule  begins  its  transformation  and  continues  in  development  after 
its  arrival  in  the  uterus.  The  modifications  to  be  disclosed  begin, 
then,  in  the  tube,  and  are  achieved  after  fixation  in  the  uterine 
cavity.  In  studying  fecundation,  we  left  the  ovule  surrounded  by 
spermatozoids.  "We  will  then  take  up  the  description  at  the  same 
point.     The  first  transformations  to  which  fecundation  gives  rise  are  : 

1.  The  formation  of  the  male  nucleus. 

2.  The  fusion  of  the  two  nuclei,  male  and  female. 

3.  Segmentation. 

4.  The  formation  of  somatopleures  and  of  splanchnopleures. 

1.  Formation  <>f  the  male  nucleus. — Spermatozoids  in  variable 
number  surround  the  ovule  ami  attempt  to  penetrate  the  vitelline 

*  I  omit  some  modifications  of  the  ovule  previous  to  fecundation  (formation  of  the 
amphiaster,  emission  of  polar  globules),  which  are  of  secondary  importance. 


28  Development  and  Description  of  the  Human  Oram. 

membrane  in  the  endeavor  to  traverse  the  vitellus  to  the  germi- 
native spot,  which  is  only  the  nucleus  of  the  ovule,  represented  in 
Fig.  8  by  the  central  black  spot.  One  of  these  spermatozoids, 
either  because  it  is  endowed  with  a  particular  vigor,  or  because  it 
finds  a  thin  and  relatively  weak  point  in  the  vitelline  envelope, 
buries  itself  in  the  surface  of  the  ovule.  At  its  approach  the  vitellus 
form  a  projection  to  meet  it,  as  if  to  invite  it  to  enter,  and  draws 
it  toward  the  centre.  To  this  momentary  projection  of  the  vitellus 
has  been  given  the  name  "cone  of  attraction."  The  spermatozoid, 
as  indicated  in  Fig.  9,  which  represents  the  successive  steps  of 
the  penetration,  continues  to  approach  the  center.  Soon  the  head 
becomes  detached  from  the  intermediary  segment  and  from  the 
tail,  the  role  of  which  is  terminated  and  which  quickly  disappear. 
In  the  interior  of  the  ovule  there  are  now  found  two  nuclei  (Fig. 
10) ;  one,  the  larger,  is  the  germinative  vesicle — the  female  nu- 
cleus of  the  ovule ;  the  other,  placed  between  the  preceding  and 
the  vitelline  membrane,  is  the  male  nucleus,  the  former  head  of  the 
spermatozoid. 

•2.  Fusion  of  the  two  nuclei. — The  male  nucleus  becomes  sur- 
rounded by  a  series  of  small  rays  which  cover  all  its  surface  like 
bristles  (Fig.  11).  Continuing  its  concentric  progress,  this  nucleus 
arrives  in  contact  with  the  female  nucleus  (Fig.  12),  with  which  it 
becomes  fused  little  by  little,  furnishing  a  series  of  appearances 
which  recall,  somewhat,  two  stars  passing  over  the  other  as  in 
eclipse.  In  Figure  13  the  eclipse  is  total,  the  fusion  of  the  two 
nuclei  complete.  The  ovule  presents  the  same  details  as  before 
i  midation,  the  vitelline  membrane,  the  vitellus,  the  germinative 
vesicle  or  nucleus,  in  winch  exists  the  germinative  spot  or  nucle- 
olius.  But  the  male  nucleus,  essentially  active,  has  been  added  to 
the  female  nucleus,  which  passively  awaited  it,  and  has  imparted 
to  the  ovule  a  new  vitality,  the  effects  of  which  are  quickly  per- 
ceived. 

3.  Segmentation. — The  ovular  nucleus  is  seen  to  divide  and  give 
birth  within  the  vitelline  membrane  to  two  distinct  cells  (Fig.  14). 
The  segmentation  continues,  in  place  of  two  cells,  four  appear  (Fig. 
15).  Finally,  by  a  series  of  analogous  divisions  (Fig.  16)  a  great 
number  of  cells  accumulate  in  the  interior  of  the  ovule,  contained 
within  the  vitelline  membrane.  We  are  now  at  about  the  eighth  day 
consecutive  to  fecundation. 

1.  Formation  of  somatoplewreB  and splanchnopleures. — In  the  center 
of  this  agglomeration  of  cells  is  formed  a  small  collection  of  liquid 
which  by  its  progressive  augmentation  pushes  back  the  cells 
entrically  nod  packs  them  into  the  vicinity  of  the  vitelline  wall 
(Fig.  17'.  All  these  cells,  which  as  a  whole  constitute  the  blasto- 
derm,  are  divided  into  three  distinct  layers  (Fig.  18).  The  ex- 
ternal,  or  ectoderm;   the  middle,  or  mesoderm,  and  internal,  or 


Development  and  Description  of  the  Human  Oram.  29 


Fig.  8. — Meeting  of  the  spermatozoids 
and  the  ovule. 


Fig.  9. — Penetration  of  the  spermatozoid. 


Fig.  10. — Ovule,  with  its  two  nuclei,      FlG.  II. — Radiations  of  the  male  nucleus, 
male  and  female. 


Fig.  12. — Approach  of  the  two  nuclei.  Fig.  13. — Fusion  of  the  two  nuclei. 


30 


Development  and  Description  of  the  Human  Ovum. 


endoderin.  The  three  layers,  external,  middle  and  internal,  of  the 
blastoderm  are  also  called  epiblast,  mesoblast  and  hypoblast  re- 
spectively. 


Fig.  14. — Segmentation. 


Fig.  15. — Segmentation. 


Fig.  i 6. — Segmentation. 


Liquid  collection  pushing 
the  cells  excentrically. 


Fig.  17. — Peripheral  accumulation  of  the  cells. 


Development  and  Description  of  the  Human  ('mm.  31 

This  division  does  not  take  place  posteriorly,  where  the  cells 
remain  packed  together,  and  there  they  soon  are  separated  by  a 
canal,  which  becomes  the  medullary  canal,  and  by  a  thickening, 

circular  on  section,  called  the  dorsal  cord  or  the  notochord,  which 
forms  the  bodies  of  the  vertebra.',  that  is,  the  most  resistant  part  of 
the  vertebral  column.  The  section  of  this  dorsal  chord  and  medul- 
lary canal  can  be  seen  in  Fig.  19. 

The  same  illustration  indicates  a  new  transformation  of  the  ovule- 
The  mesoderm,  or  the  middle  layer  of  the  blastoderm,  is  separated 
into  two  rows  of  cells,  the  external  adhering  to  the  ectoderm  and 
the  internal  to  the  endoderm.  By  this  separation  the  three  layers 
now  form  only  two  : 

An  external,  called  the  somatopleure. 

An  internal,  called  the  splanchnopleure.  The  somatopleure  forms 
the  envelope  and  the  framework  of  the  body,  the  splanchnopleure, 
the  viscera. 

To  facilitate  the  comprehension  of  the  preceding  illustration, 
the  two  layers,  formed  by  cells  composing  the  splanchnopleure  and 
the  somatopleure,  will  be  represented  by  a  unique  character  as 
shown  in  Fig.  20,  which  is  otherwise  identical  with  Fig.  19. 

These  two  layers  are  blended  behind  in  a  common  mass  in 
which  is  perceived  the  dorsal  cord  and  the  medullary  canal.  The 
somatopleure  and  the  splanchnopleure,  which  were  disposed  in  a 
circular  manner  (Fig.  20),  next  undergo  a  strangulation  in  their 
middle  portion  as  indicated  in  Fig.  21.  This  strangulation  divides 
these  two  membranes  into  two  distinct  regions : 

One.  embryonic  (inferior,  Fig.  21). 
The  other,  extra-embryonic  (superior). 

The  embryonic  portion  is  united  to  the  extra-embryonic  by  the 
intermediate  or  constricted  region.  Xow  these  three  parts  have,  in 
the  ulterior  development  of  the  ovum,  different  roles  to  fulfill. 

The  extra-embryonic  part  will  form  the  envelopes  of  the  ovum  and 
the  placenta. 

The  intermediate  part  will  form  the  cord. 

The  embryonic  part  will  form  the  fcetus. 

Let  us  study  successively  the  development  of  each  of  these  parts 
and  their  constitution  after  complete  formation. 

I.  Extra-embryonic  portion  of  the  ovum. — Membranes. — 

Placenta— Amniotic  liquor —The  extra-embryonic  part  of  the  ovum 
is  formed,  as  we  have  seen  in  Fig.  21,  by  the  extra-embryonic 
somatopleure  and  splanchnopleure,  separated  by  a  virtual  space 
called  the  external  co?lum  (the  internal  cceluni  is  an  analogous  space 
found  at  the  embryonic  part).     The  real    cavitv  formed   bv  the 


32  Development  and  Description  of  the  Human  Ovum. 

extra-embryonic  splanchnopleure  is  called  the  umbilical  vesicle  and 
contains  the  elements  for  the  nutrition  of  the  ovum  until  the  for- 
mation of  the  placenta.  This  umbilical  vesicle  corresponds,  as  to 
its  contents,  to  the  yolk  of  the  eggs  of  birds.  While  the  wall  of  the 
umbilical  vesicle,  formed  by  the  splanchnopleure,  undergoes  an 
atrophy  and  a  progressive  retreat,  the  suprajacent  layer,  on  the 
contrary,  which  is  only  the  extra-embryonic  somatopleure,  takes  on 
a  considerable  and  rapid  development  to  constitute  the  secondary 
chorion  and  the  amnion.  The  layer  of  the  somatopleure,  is  seen  to 
throw  out  a  series  of  prolongations,  indicated  by  the  successive 
tracings  1,  2,  3,  4  (Fig.  22).  These  prolongations  meet  one  another 
by  surrounding  the  ovule;  their  reunion  quickly  occurs  at  a  point 
opposite  to  their  origin.  When  this  reunion  is  achieved  (Fig.  23),  i.  e., 
of  the  two  layers  created  by  this  prolongation,  one  is  directly  applied 
to  the  internal  surface  of  the  vitelline  membrane  over  all  its  extent ; 
the  other,  continuing  with  the  intermediate  somatopleure,  lines  a 
part  of  the  external  surface  of  the  umbilical  and  of  the  internal 
surface  of  the  preceding  layer;  while  between  them  and  the 
embryo  exists  an  actual  cavity  in  which  is  collected  the  amniotic 
fluid. 


Endoderm.  Hypoblast.  Internal  layer. 
Mesoderm.   Mesoblast.    Middle  layer. 

Ectoderm.    Epiblast.     External  layer. 
Vitelline  membrane. 


FlG.  i8. — Formation  of  the  three  blastodermic  layers. 

The  primary  chorion  is  formed  by  the  vitelline  membrane, 
the  surface  of  which  is  covered  at  a  certain  time  with  villi.  The 
secondary  chorion  is  created  by  the  addition  of  the  layer  of  the  extra- 
embryonal  somatopleure  to  the  vitelline  membrane.  These  two 
membranes  undergo  a  true  fusion  to  form  the  secondary  chorion.  The 
membrane  which,  in  Fig.  23,  is  found  under  the  secondary  chorion, 
is  the  amnion.  In  the  space  which  separates  them  is  developed  the 
definitive  chorion,  as  we  shall  see. 


Development  and  Description  of  the  Human  Ovum.  33 


FlG.  19. — Formation  of  somatopleure  and  splanchnopleure.     I,  splanchnopleure; 
2,  somatopleure;  3,  dorsal  cord;  4,  medullar}-  canal. 


Fig.  20. — Simplification  of  Fig.  19.     1,  chorial  villi;  2,  vitelline  membrane: 
3,  somatopleure;   4,  splanchnopleure. 

From  the  embryo,  between  the  somatopleure  and  the  splanchno- 
pleure, in  the  pelvic  region,  is  developed  a  hollow  bud,  which  pro- 
gressively enlarges  separating  the  two  limiting  membranes,  this  is 


34 


A  velopment  and  Description  of  the  Human  Ovum. 


the  allantois.  Its  embryonic  part  becomes  the  bladder  and  the 
urachus  and  its  extra-embryonic  part  forms  the  third  chorion  (or 
definitive)  and  the  placenta.  Fig.  24  shows  the  first  steps  of  the 
development  of  the  allantois.  Fig.  25  defines  a  more  advanced 
stage.  The  allantois  progressively  invades  the  space  which  separates 
the  secondary  chorion  from  the  amnion.  It  may  be  compared  to 
an  umbrella,  the  handle  forming  the  cord  and  the  spread  portion 
extending  more  and  more  to  envelope  the  embryo  as  in  1, 2,  3,  4  (Fig. 
25).  We  are  now  at  about  thet  wenty-fifth  day  consecutive  to  the 
fecundation. 

^Chorial  villi. 

Vitelline  membrane. 

Somatopleure. 

Splanchnopleure. 
Extra-embryonic  part 

External  coelom. 


Intermediate  part  of 
the  ovum. 


Embryonic  part  of  the 

ovum 
Som-topleure. 
Splanchnopleure. 


—  Internal  coelom. 


Fig   21. — Strangulation  of  the  ovum. 

At  the  end  of  the  first  month  the  allantois  is  at  the  height  of  its 
development.  It  has  carried  with  it,  over  all  the  internal  surface  of 
the  secondary  chorion,  vascular  ramifications,  which  are  prolonged 
into  the  villi.  The  umbilical  vesicle,  after  the  absorption  of  its 
contents  for  the  development  of  the  ovule,  progressively  atrophies. 

I  luring  all  the  second  month  the  enveloping  membranes  change 
but  little,  they  undergo  a  development  as  a  whole,  all  their  surface 
is  covered  by  vascular  villi,  so  that  the  shaggy  ends  of  these 
structures  can  be  easily  seen  by  floating  the  ovum  in  water. 

During  the  third  month,  the  villi  which  cover  the  surface  of  the 
ovum  atrophy  except  at  the  point  where  the  ovum  adheres  to  the 
uterus  and  there  they  take  on  a  remarkable  development.  This 
hypertrophied  region,  where  all  the  life  of  the  allantois  seems  local- 
ized, becomes  the  placenta  ;  over  all  the  rest  of  its  extent  the  allantois 
atrophies,  as  indicated  in  Fig.  26. 


Development  and  lh- script  ion  of  the  Human  Ovum.  35 

Outside  the  placenta]  zone  the  aUantois  is  entirely  united  to  the 
secondary  chorion,  as  indicated  in  a  limited  region  of  Pig.  26; 
thus  is  formed  the  tertiary  or  definitive  chorion.  Thus  it  is  Si  en 
that  the  primary  chorion  is  formed  by  the  vitelline  membrane,  the 
secondary  by  the  extra-embryonic  somatopleure ;  the  tertiary  by  the 
aUantois. 


Fig.  22. — Prolongations  of  the  extra- embryonic  somatopleure. 

The  umbilical  vesicle  continues  to  atrophy.  This  atrophy  is 
complete  at  the  end  of  the  third  month,  and  at  this  moment 
nutrition  by  the  placenta  is  definitely  substituted.  Consequently  at 
this  time  the  embryo  becomes  the  foetus ;  that  is,  at  the  end  of  the 
third  month,  or  at  the  commencement  of  the  fourth,  the  reign  of 
the  aUantois,  i.  e.,  the  placenta,  replaces  that  of  the  umbilical  vesicle. 
Tins  vesicle  atrophies  so  completely  that  it  is  difficult  to  find  traces 
of  it  in  the  ovum  at  term. 

The  ovum  during  the  evolution  that  we  have  now  to  follow,  is  en- 
closed and  protected  by  the  uterine  mucosa,  which  takes  a  special 
evolution  transforming  it  into  a  new  membrane  called  the  decidua, 
thus  designated  because  it  is  destined  to  being  cast  off  at  the  same 
time  with  the  ovum. 

The  preceding  description  has  given  us  a  summary  of  the  for- 
mation of  the  placenta,  of  the  chorion,  of  the  amnion,  of  the  decidua 


36 


Development  and  Description  of  the  Human  Ovum. 


and  of  the  amniotic  fluid ;  we  have  now  to  study  the  details,  which 
will  initiate  us  more  intimately  into  the  constitution  of  these  dif- 
ferent parts,  by  taking  as  a  type  the  ovum  nearly  arrived  at  term. 
But  before  beginning  this  detailed  description,  it  is  indispensable  to 
embrace  at  a  glance  the  general  configuration  of  the  ovum  enclosed 
by  the  uterus.  The  schematic  section  represented  by  Fig.  27 
permits  us  to  easily  grasp  this  as  a  whole. 


Fig.  23. — Formation  of  the  amnion  and  secondary  chorin.  I,  vitelline  membrane 
or  primitive  chorion  :  2,  umbilical  vesicle;  3,  secondary  chorion;  4,  amnion;  5,  amni- 
otic cavity  containing  the  amniotic  liquid. 

Here  there  is  seen,  in  passing  from  the  uterus  to  the  foetus : 

1.  The  uterine  wall,  thin  in  the  inferior  segment  at  the  cervix. 

2.  The  uterine  mucosa  (partially  transformed  into  the  clecidua), 
considerably  thickened  at  the  placenta  and  divided  in  the  rest  of 
it  extent  into  two  layers,  one  applied  directly  on  the  ovum  (ovuline 
decidua),  the  other  to  the  inner  surface  of  the  uterus  (uterine  de- 
ci  lua) ;  the  latter  is  continuous  interiorly  with  the  cervical  mucosa. 
"We  shall  study  later  the  formation  of  these  membranes. 

3.  The  chorion,  considerably  hypertrophied  in  one  region  to  con- 
stitute the  placenta,  and  atrophied,  on  the  contrary,  in  the  rest  of 
its  extent,  where  it  is  enclosed  between  the  ovuline  decidua  and  the 
amnion. 


Development  and  Ih-script'um  of  the  Human  Ovum. 


37 


4.  The  amnion,  which  is  the  most  internal  membrane. 

5.  The  amniotic  fluid,  which  fills  the  cavity  of  the  amnion,  and 
in  which  tioats  the  fcetus  connected  to  the  placenta  hy  the  cord. 


Fig.  24. — Formation  of  the  allantoic  bud.     1,  progression  of  the  allantoic 
bud;  2,  allantoic  bud. 

We  shall  study  these  different  parts  in  the  following  order:  I. 
Placenta.  II.  Chorion.  III.  Amnion.  IV.  Decidual  membranes. 
V.  Liquor  amnii. 


I.  Placenta. — The  placenta,  forming  the  union  between  the 
maternal  and  fcetal  circulations,  is  a  fleshy  and  vascular  disc,  termi- 
nating by  one  of  its  surfaces  in  the  cord,  the  other  adhering  to  the 
internal  wall  of  the  uterus.  Its  weight  is  about  five  hundred 
grammes,  nearly  that  of  the  liquor  amnii,  so  that  the  foetal  append- 
ages represent  approximately  a  kilogramme.  Dimensions:  twenty 
centimetres  in  diameter  or  a  little  less ;  three  centimetres  in  thick- 
ness toward  the  center,  pressively  thin  toward  the  edge.  To  under- 
stand this  organ  completely  it  is  necessary  to  study:  1.  Its  foetal 
surface;  2.  Its  uterine  surface;  3.  Its  circumference:  4.  It- 
structure;  5.  Its  physiology. 

1.  The  foetal  surface,  in  contact  with  the  liquor  amnii,  is  smooth 


38 


Development  and  Description  of  the  Human  Ovum. 


in  all  its  extent,  for  it  is  covered  by  the  amnion,  winch  can  easily 
be  detached.  It  is  grooved  by  the  vessels  formed  by  the  expansion 
of  funicular  arteries  and  veins. 


FlG.  25. — Development  of  the  allantois.     1,  secondary  chorion  (the  two 
membranes  being  united  in  one). 

The  insertion  of  the  cord  may  occur  in  four  different  regions 
(Fig.  29) : 

1.  At  the  center  of  the  placenta  (central  insertion). 

2.  Between  the  center  and  the  periphery  (lateral  insertion). 

3.  At  the  margin  of  the  placenta  (marginal  insertion). 

4.  On  the  membranes  (velamentous  insertion). 
Their  relative  frequency  is  as  follows  : 

Central  and  lateral  insertion  (equally  frequent)  95  per  100. 
Marginal  insertion  4  per  100. 
Velamentous  insertion  1  per  100. 
In  cases  of  velamentous  insertion,  which  may  occur  up  to  twenty 
centimetres  from  the  placental  margin,  the  vessels  may  ramify  in 
the  membranes  (Benekiser),  or,  on  the  contrary,  they  may  pursue 
isolated  courses  up  to  the  placenta  before  dividing  (Lobstein). 

2.  The  uterine  swrface  is  unequally  projecting  and  flocculent,  and 
divided  into  lobes  or  cotyledons  by  a  number  of  more  or  less  marked 


Development  and  Description  of  the  Human  Ovum. 


39 


grooves.  These  Lobes,  to  the  number  of  ten,  fourteen,  or  more,  are 
divided  into  Lobules,  which  are  composed  by  a  grouping  of  villi.  It 
is  by  this  surface  that  the  placenta  is  adherenl  to  the  uterus.    To 

state  this  insertion  exactly,  it  is  important  to  divide  the  internal 
Burface  of  the  uterus  by  two  parallel  plans  AB,  CD  (Fig.  81)  pass- 
ing one  at  eight  centimetres  below  the  fundus  of  the  uterus,  the 
other  at  eight  centimetres  from  the  internal  orifice.  According 
to  a  series  of  measurements  that  I  have  math-,  it  results  that  the 
distance  which  separates  the  two  planes  AB  ami  CD,  hy  following 
the  uterine  wall,  is  about  sixteen  centimetres. 


Fig.  26. — Formation  of  the  placenta  and  tertiary  or  definite  chorion.  I,  remains  of 
the  umbilical  vesicle;  2,  tertiary  or  definite  chorion;  3,  placental  villi;  4,  placenta; 
5,  allantois. 

Every  placenta  which  by  any  part  of  its  surface  is  inserted  below 
the  plane  CD,  that  is  to  say  which  encroaches  on  the  uterine  circle 
blended  with  plane  CD,  is  an  inferior  polar  placenta,  or  a  placenta 
prcevia. 

Likewise,  every  placenta  which  by  any  portion  of  its  extent  is  in- 
serted above  the  plane  AB  is  a  superior  polar  placenta. 

Every  placenta  inserted  between  these  two  planes  may  be  called 


40 


Development  and  Description  of  the  Human  Ovum. 


equatorial,  for  its  center  coincides  with  the  equator  of  the  uterus, 
but  this  variety  is  rare,  the  diameter  of  the  placenta  being  usually 
greater  than  sixteen  centimetres  and  thus  encroaching  on  one  of 
the  polar  circles.  From  the  statistics  of  forty-eight  cases  I  ha^e 
found  : 

Inferior  polar  placenta  in  one-third  of  the  cases. 

Superior  polar  placenta  in  two-thirds  of  the  cases. 

Equatorial  placenta,  exceptionally. 
The  inferior  polar  placenta,  or  placenta  prsevia,  gives  rise  to  a 
series  of  accidents  which  will  be  studied  later. 


Frr,.  27. — Ovum  definitely  formed.  1,  remains  of  the  umbilical  vesicle;  2,  maternal 
placenta;  3,  fcetal  placenta;  4,  cord;  5,  amnion;  6,  chorion;  7,  ovuline  decidua; 
8,  decidua  and  uterine  mucosa;   9,  uterine  wall. 

3.  The  circumference  of  the  placenta  is  constituted  by  the  union 
of  the  membranes  with  this  organ.  This  placental  margin,  regular 
in  a  rounded  or  oval  placenta,  becomes  more  or  less  tortuous  when 


Development  and  De$<-ri]>tion  of  the  Human  Chum.  41 


FlG.  28. — Foetal  surface  of  the  placenta,  with  amnion  partly  uplifted. 


Fig.  29. 


Fig.  30. — Uterine  surface  of  the  placenta. 


42 


Development  and  Description  of  the  Human  Ovum. 


the  form  departs  from  the  normal  type.     Thus  we  are  led  to  say  a 
few  words  on  the  different  forms  of  placenta  in  simple  pregnancy : 

A.  Sometimes  the  placenta  is  unilobed,  the  most  frequent  form. 

B.  Sometimes  it  is  multilobed,  but  not  having  the  lobes  entirely 
separated. 

C.  Sometimes  it  is  multilobed,  with  the  lobes  so  distinct  that 
there  appear  to  be  several  placentas. 


Fig.  31. 


As  examples  of  these  varieties  we  have  under 
A.  Unilobed  placenta. 


Fig.  32. 


1.  Circular  form  (Fig.  32). 


Development  and  Description  of  tlis  Human  Ovum.  43 


2.  Oval  form  (Fig.  33). 


Fig.  33. 


Fig.  34. 


3.  Irregular  form  (Fig.  34). 


44  Development  and  Description  of  the  Human  Ovum. 

B.   United  multilobed  placenta. 


Fig.  35. 


1.  Two  equal  lobes  (Fig.  35). 


Fig.  36. 
2.  Two  unequal  lobes  (Fig.  36). 


Development  and  Description  oj  the  Human  Ovum.  i.~> 


Fig  37. 

3.  There  exist  more  than  two  lobes  (Fig.  37). 


C.  Placenta  with  separate  lobes. 


Fig  38. 
(a).  Two  equal  lobes  (Fig.  38). 


46 


Development  and  Description  of  the  Human  Ovum. 


Fig.  39. 
(b).  Two  unequal  lobes  (Fig.  39). 


Fig.  40. 
(c).  More  than  two  lobes  (Fig.  40). 

4.  Structure. — Let  us  take  a  perpendicular  section  of  the  uterine 
Avail,  the  placenta,  and  the  cord,  as  represented  in  the  schematic 
illustration  of  Fig.  41.  We  then  find,  from  the  superficies  toward 
the  center : 

1.  Beneath  the  peritoneum  (which  is  not  given  in  the  illustration) 
the  muscular  wall. 

2.  Beneath  the  uterine  mucosa,  transformed  into  the  maternal 
placenta  containing  a  series  of  lacunar  spaces,  the  remains  of  the 
glandular  culs-de-sac  more  or  less  modified  and  terminating  super- 
ficially in  a  series  of  villi. 

3.  The  foetal  placenta,  shaggy  on  the  uterine  side,  by  virtue  of  its 
rich  mass  of  villi  interlacing  with  those  of  the  maternal  placenta; 
smooth  on  the  foetal  side,  where  it  is  in  contact  with  the  amnion. 


Development  and  Description  of  th   Human  Ovu 


in. 


47 


4.  Finallj,  ibe  umbilical  cord. 

Through  all  these  tissue,  i>  found  a  vascular  network,  tin-  details 
of  which  I  shall  give  alter  having  explained  at  greater  length  these 
different  part-. 


\rcular  venous  sinus  (maternal 
placenta). 


Vein  of  maternal  placenta. 


bmus. 
Funicular  artery. 


Funicular  vein. 
An  isolated  villus. 

Sinus. 
Villus  of  foetal  placenta. 

Villus  of  maternal  placenta. 

Maternal  placenta. 

Glandular  opening. 

Amnion. 
— Chorion. 

Ovuline  decidua. 
Uterine  decidua. 

Fig.  41. — Schema  representing  the  structure  of  the  placenta. 

A.  Maternal  placenta. — The  uterine  mucosa,  transformed  in  the 
placental  region,  is  divided  into  two  parts,  separated  by  the  more  or 
less  regular  line  of  the  glandular  lacuna?.  It  is  at  this  place  that 
separation  occurs  at  delivery,  the  eccentric  part  remaining  adherent 
to  the  uterus  to  constitute  the  new  mucosa,  the  other  portion,  the 
decidual,  follows   the    placenta.     When    we   examine    the   uterine 


48  Development  and  Description  of  the  Human  Ovum. 

surface  of  a  recently-expelled  placenta,  it  is  the  portion  corre- 
sponding to  this  series  of  lacuna?  that  meets  our  eyes.  The  part 
near  the  fcetal  placenta  terminates  in  series  of  villi,  somewhat 
projecting  and  ramifying.  In  a  vascular  point  of  view,  these  villi 
are  of  two  kinds,  as  will  be  seen  in  Fig.  41.  In  one  variety  the 
artery  is  continuous  with  the  vein  after  having  formedd  a  more 
or  less  rich  vascular  network.  In  another  the  artery  opens  directly 
by  one  or  two  orifices  into  spaces  called  sinuses.  From  these  villi 
arise  other  veins.  In  this  way  the  blood  returns  into  the  venous 
system  and  enters  the  uterine  sinuses  directly  or  by  the  interme- 
diate circular  sinus  which  exist  around  the  placenta. 

B.  Foetal  placenta. — The  framework  of  the  fcetal  placenta  is 
formed,  like  that  of  the  maternal,  of  connective  tissue,  with  fusi- 
form and  star-shaped  cells.  It  is  adherent  by  its  fcetal  surface  to 
the  chorion,  of  which  it  is  only  the  expansion,  and  is  united  to  the 
maternal  placenta  by  a  series  of  rich  and  luxurious  villi.  The  villi 
are  of  two  kinds :  one  absolutely  free,  floating  without  adhesions  in 
the  sinuses,  the  other  terminating  by  the  extremity  in  the  maternal 
placenta.  These  villi  are  furnished  with  vessels  in  the  form  of  a 
capillary  network  with  an  apparent  artery  and  an  afferent  vein. 

From  the  preceding  description  it  is  seen  that  the  union  of  the 
two  placentas,  fcetal  and  maternal,  occurs  through  the  intermediate 
villi.  Some  of  the  maternal  and  fcetal  villi  are  in  contact,  and  some 
are  separated  by  the  blood  of  the  sinus  which  surrounds  them  like 
an  atmosphere.  The  blood  of  these  sinuses  is  exclusively  maternal. 
There  is  no  direct  communication  between  the  blood  of  the  mother 
and  that  of  the  foetus,  but  a  simple  mediate  contact,  through  the 
flattened  epithelium  which  forms  a  continuous  layer  at  the  surface 
of  the  villi,  and  through  the  walls  of  the  vessels.  The  physiological 
changes  which  we  have  now  to  study  occur  through  the  medium  of 
this  barrier. 

5.  PJiysiology. — In  the  placenta,  the  foetal  and  the  maternal  blood 
being  in  mediate  contact,  the  foetal  blood  is  relieved  of  its  carbonic 
acid  and  absorbs  oxygen,  just  as  this  occurs  in  the  lungs  of  an 
adult.  Thus  a  veritable  respiration  takes  place  at  this  point. 
Besides  this,  the  nutritive  elements  contained  in  the  maternal 
blood  are  absorbed  by  the  foetal  blood,  so  that  the  placenta  plays 
a  double  role,  respiratory  and  nutritive,  taking  the  place,  for  the 
foetus,  of  the  lungs  and  of  the  digestive  tract.  Aside  from  the 
i mri nal  constituents  carried  by  the  maternal  blood,  there  may  be 
abnormal  elements,  such  as  the  different  medicaments  and  divers 
microbes.  The  iodide  and  chlorate  of  potash  and  salycilic  acid 
ingested  by  the  mother  during  labor  are  found  after  birth  in  the 
foetal  organism.  The  same  is  true  of  potassium  nitrate,  of  yellow 
prussiate  of  potash,  of  bromide  of  potassium  and  sulphate  of  quinine, 
but   their  passage  is  slower.     Chloroform  also  passes  from  the 


Development  and  Description  of  tht   Human  Ovum.  A'.' 

mother  to  the  foetus,  but  without  danger  to  the  child.  Solid 
elements  may  pass  through  the  placenta.  The  transmissi 
microbes  has  been  recently  established.  The  majority  of  the 
pathogenetic  microbes  traverse  the  pla  ;enta  but  with  unequal 
facility.  However,  the  placenta  ie  not  a  simple  filter,  it  also 
possesses  the  power  of  producing  sugar ;  the  glucogenic  function 
identical  with  that  pertaining  to  the  adult  liver.  The  placenta  not 
only  serves  the  foetus  as  a  digestive  tube  and  lung,  but  also  t 
the  part  of  the  hepatic  gland. 

II.  The  Chorion. — This  simple  name  is  given  to  the  tertiary 
or  definitive  chorion.  Situated  between  the  decidua,  which  covers 
its  external  surface,  ami  the  amnion,  which  lines  its  internal 
surface,  it  is  more  adherent  to  the  first  than  to  the  second.  The 
adhesion  with  the  decidua  is  immediate,  that  with  the  amnion  is 
mediate  and  occurs  through  an  intermediate  glutinous  substance, 
the  reticulated  magma.  This  disposition  explains  why  the  amnion 
is  so  easily  detached  from  the  chorion  during  labor,  while  detach- 
ment of  the  chorion  from  the  decidua  is  rarely  observed  :  and  why 
the  liquor  amnii,  transuding  through  the  amnion,  so  easily  accumu- 
lates ]  etween  this  membrane  and  the  chorion. 

The  chorion  is  composed  of  a  stroma  of  connective  tissue.  It- 
external  surface  is  covered,  by  a  layer  of  pavement  cells,  with  which 
it  is  in  contact  with  the  decidua.  Rich  in  vessels  at  the  second 
month  of  gestation,  it  is  completely  deprived  of  them  after  the 
complete  and  definitive  formation  of  the  placenta ;  however,  ex- 
ceptionally these  vessels  may  persist. 

III.  Amnion. — The  amnion  is  the  most  internal  membrane  of 
the  ovum.  After  having  covered  all  the  internal  surface  of  the 
ovum  it  is  continued  on  the  placenta  and  then  to  the  cord,  which 
it  surrounds  like  a  sheath,  terminating  at  the  umbilicus,  where  the 
cutaneous  covering  of  the  fcetus  begins.  The  amnion  i-  composed 
of  two  layers  :  an  external,  containing  connective  tissue  with  some 
non-striated  muscular  fibres,  and  an  internal,  or  epithelial,  directly 
in  contact  with  the  liquor  amnii.  Vessels  are  wanting,  except  in 
the  vicinity  of  the  placenta,  where  during  the  first  months  of  pi  g 
nancy  are  met  the  vasa  propria  which  secrete  the  amniotic  liquor, 
and  the  abnormal  persistence  of  which  would  be  one  of  the  causes 
of  hydramnios. 

IV.  Decidual  Membranes. — The  decidual  membranes  being 
formed  at  the  expense  of  the  uterine  mucosa,  are  then  of  maternal 
origin.  I  shall  describe  them  here,  however,  becau>e  their  union  with 
the  ovum  is  so  intimate,  and  because,  as  their  name  indicates,  they 
are  cast  off  with  it.     The  decidual  membranes  are  three  in  number. 


50 


Development  and  Description  of  the  Human  Ovum. 


the  uteroplacental,  the  uterine,  and  the  ovuline.  How  are  these 
decidual  membranes  formed  ?  On  the  arrival  of  the  ovum  in  the 
uterine  cavity  it  lodges  in  the  mucous  folds  as  indicated  in  Fig. 
42.  The  two  projections  of  the  mucosa,  which  limit  the  fold  in 
which  the  ovule  reposes,  take  on  a  rapid  development  and  surround 
the  ovule  more  and  more  (Fig.  43).  Soon  they  enclose  it  com- 
pletely, as  in  Fig.  41.  At  this  moment  there  exist  three  distinct 
parts  :  The  first  is  formed  by  the  union  between  the  ovum  and  the 
uterine  wall;  this  is  the  utero-placental  decidua,  formerly  called 
the  serotrine  decidua.  The  second  lines  the  uterine  wall  and  only 
undergoes  slight  modifications ;  this  is  the  uterine  or  true  decidua. 
The  third  directly  covers  ths  ovum,  by  means  of  the  development 
already  described ;  this  is  the  ovuline  decidua  or  decidua  rejiexa. 


Fig.  42. 


Fig.  43.  Fig.  44. 

Enclosure  of  the  ovum  by  the  uterine  mucosa. 


Fig.  45. — Disposition  of  the  deciduas  in  relation  to  the  ovum  and  uterine  wall.     I, 
fjlacenta;   2,  uterine  wall ;  3,  uterine  decidua;  4,  ovuline  decidua;  5,  ovum. 

These  three  decidual  membranes  being  known,  let  us  follow  their 
evolution.     During  the  first  three  months  of  pregnancy,  the  ovuline 


Development  and  Description  of  the  Human  Oram. 


51 


and  the  uterine  deciduas  are  separated  by  a  Bpace,  which  permits 
the  passage  of  the  spermatozoids  to  the  tube  and  a  second  fecun- 
dation after  the  first.  These  tacts  will  be  Btudied  later  under 
super-fecundation.  With  the  second  three  months  the  conditions 
change,  the  ovuline  and  the  uterine  deciduas  are  in  contact  and 
quickly  contract  intimate  adhesions  in  such  a  manner  (Fig.  45) 
that  the  uterine  wall  is  fused  with  the  ovum ;  thus,  at  this 
moment,  super-fecundation  becomes  impossible  unless  a  double 
uterus  exists.  It  is  likewise  understood  why  abortion  during  the 
second  three  month-  is  so  often  accompanied  by  the  retention  of 
membranes  and  especially  of  the  decidua. 


Uterine  muscle.  — 


Glandular 
culs-de-sac. 


Spindle-shaped 
cells. 


Round  cells. 


Chorion. 
Amnion. 


Robin. 


,  Sinety. 


Friedlander. 


Fig.  46. — Section  of  the  internal  wall  and  of  the  membranes. 

During  the  last  three  months,  separation  from  the  ovum  and 
from  the  uterine  wall  is  progressive.  As  for  the  placenta  separation 
occurs  at  the  moment  of  delivery  at  the  level  of  the  glandular  culs- 
de-sac.  As  to  the  membranes,  opinions  differ.  To  comprehend 
the  place  where  separation  occurs,  let  us  follow  (Fig.  46)  the 
different  layers  met  in  going  from  the  uterus  to  the  liquor  amnii. 
Beneath  the  peritonseum,  not  represented  in  the  illustration,  is  found 
the  uterine  muscle,  then  the  mucosa  and  the  united  deciduas  in 
three  layers  :  the  first  lamina  strewn  with  glandular  culs-de-sac,  the 
second  composed   of   elongated   cells,    the    third    of  round   cells. 


52 


Development  and  Description  of  the  Human  Ovum. 


Concentrically  are  the  chorion  and  the  amnion.  Now,  the  sepa- 
ration occurs : 

According  to  Robin,  at  the  union  of  the  muscle  with  the  mucosa, 
which  thus  is  cast  off  as  a  whole,  leaving  the  uterine  wall  naked. 

According  to  Sinety,  at  the  level  of  the  glandular  culs-de-sac.  the 
same  as  the  placenta. 

According  to  Friedlander,  in  the  middle  of  the  layer  of  elongated 
cells. 


Fig.  47. — Evolution  of  the  ovuline  and  uterine  deciduas.  1,  glandular  culs  de- 
sac;  2,  placenta;  3,  uterine  wall;  4,  ovum;  5,  uterine  decidua;  6,  membrane  of  new 
formation  covering  the  non-decidous  mucosa;  7,  non  decidous  uterine  mucosa;  8, 
ovuline  decidua;  9,  cervix;   10,  mucosa  of  the  cervix. 

With  regard  to  the  decidua,  the  opinion  of  Sinety  appears  the 
most  admissible.  For  the  membranes  as  for  the  placenta  separation 
occurs  at  the  level  of  the  glandular  culs-de-sac,  the  superficial 
portion  of  the  uterine  decidua  remaining  adherent  to  the  ovuline 
decidua  (Fig.  47)  and  thus  only  this  superficial  portion  is  cast  off 
with  the  foetus.  At  the  moment  of  term,  the  detachment,  which 
commences  in  the  vicinity  of  the  internal  orifice,  and  gains  the 
fundus  by  degrees,  is  usually  complete  or  at  least  very  extended. 


Development  and  Description  of  the  Human  Ovum. 

V.  Liquor  Amnii. — The  amniotic  fluid  appears  a  little  afterthe 
formation  of  the  amnion.     At  four  months  and  a  half  it-  weight  is 

equal  to  that  of  the  I'm  tn~.     A.t  term  it  amounts,  on  the 
to  half  a  litre.     However,  there  are  very  extensive  variations.    But 
when  the  quantity  exceeds  a  litre  there  results  the  pathological 
state  known  as  hydramnios,  a   question   belonging  to  puerperal 
pathology.     Clear  and  transparent  in  the  1  eginning  of  pregna 
Blightly  yellow  at  the  end,  in  the  pathological  state  it  may  become 
greenish  or  red.     This  liquid,  in  which  is  found  some  • 
proceeding  from  the  epidermis  of  the  foetus,  from  the  renal  and 
from  the  amniotic  epithelium,  contains  chiefly  chloride  of  sodium, 
lactate  of  Bodium  and  albumin. 

The  origin  of  the  liquor  amnii  is  not  yet  definitely  settled.  Some 
suppose  that  it  proceeds  from  the  mother,  by  filtration  through  the 
membranes  into  the  amniotic  cavity.  Others  believe  it  to  proceed 
from  the  ovum,  arising  from  the  annexes,  from  the  vasa  propriaof 
Junghluth,  from  the  cord,  or  from  the  foetus  itself  by  lenal  and 
cutaneous  secretions. 

Physiology. — The  uses  of  the  amniotic  liquid  are  multiple.  By 
its  presence  it  creates  a  veritable  liquid  atmosphere  for  the  foetus. 
If  the  uterine  wall  was  applied  on  the  foetus,  funicular  circulation 
would  certainly  be  impossible.  During  labor,  the  liquor  amnii 
accumulating  in  the  bag  of  waters,  favors  the  opening  of  the  genital 
canal. 

II.  Intermediate  portion  of  the  ovurn.— The  cord. — The 
umbilical  cord  is  the  flexible  stem  which  joins  the  placenta  to  the 
foetus.     We  have  already  seen  its  formation. 


Fig.  48. —  Straight  cord. 


Fig.  49. — Twisted  cord. 

External  conformation. — Smooth  and  whitish  at  its  superfV 
the  cord  sometimes  represents  a  plain  stem  (Fkr.  48),  sometii. 
on  the  contrary,  a  stem  twisted  on  itself,  and  this  tortion  may  be 
directed  from  right  to  left  (Fig.  49),  or  from  left  to  right.  Some- 
times on  the  same  cord  a  torsion  in  an  inverse  direction  is  noted 
at  the  two  extremities.  The  relative  frequency  of  the  different 
varieties  of  funicular  torsion  (the  spiral  will  be  described  by  follow- 
ing the  cord  from  below  upward  1  may  be  indicated  by  the  following 
figures : 


54 


Development  and  Description  of  the  Human  Ovum. 


Sinistro-torsion,  72  per  100. 
Dextro-torsion,  25  per  100. 
Double  torsion,  1  per  100. 
No  torsion,  2  per  100. 

The  torsion  of  the  cord  is  due  to  the  disposition  of  the  vessels, 
which  will  be  studied  later. 


Fig.  50. — Circular  nodosity. 


Fig.  51. — Sessile  and  pedunculated 
nodosities.  I,  pedunculated  nodosity; 
2,  sessile  nodosity. 


The  usual  length  is  fifty  centimetres  at  term.  Variations :  maxi- 
mum, one  metre,  seventy-eight  centimetres  (Neugebauer) ;  mini- 
mum, total  absence,  where  the  umbilicus  is  adherent  to  the  placenta. 
The  size  is  nearly  that  of  the  little  finger.  Variations :  maximum, 
seven  centimetres  and  one-half  in  circumference  (Bell) ;  minimum, 
the  size  of  a  goose  quill  (Scanzoni).  Much  more  marked  restrictions 
may  exist  and  compromise  the  circulation.  On  the  cord  are  often 
found  nodules,  that  may  be  circular  (Fig.  50),  sessile  or  peduncu- 
lated (Fig.  51).  The  contents  of  these  nodules  may  be  gelatinous 
(Wharton's  jelly),  arterial  (vascular  loop),  or  vercaS  (venous  loop 
or  venous  dilatation).  With  these  nodules,  or  simple  swellings  of 
the  cord,  there  must  not  be  confused  the  true  knots,  which  will  be 
studied  under  pathology.  The  insertion  of  the  cord  takes  place  for 
one  part  at  the  umbilicus  and  for  the  other  part  at  the  internal 
surface  of  the  placenta.  The  latter  insertion  has  been  fully 
described. 

Interior  con  formation. — When  the  cord  is  cut  transversely,  it  is 
found  composed  (Fig.  52)  of  a  continuous  amniotic  envelope,  filled 


Development  and  Description  of  the  Human  Owm. 


.,., 


and  distended  by  Wharton's  jelly.  En  this  substance  are  contained 
three  vessels,  a  large  vein  and  two  small  arteries.  The  relative 
disposition  of  these  vessels  is  variable.  The  arteries  and  the  \<  in 
may  pursue  a  parallel  course  without  a  trace  of  twi-tiii'_r  (Fig.  58). 
The  vein  may  be  twisted  around  the  arteries  (Fig.  54)  in  a  spiral 
form.  The  two  arteries  may  twist  around  the  vein  (Fig.  55). 
Finally,  the  twisting  of  the  three  vessels  may  be  simultaneous  ami 
reciprocal  (Fig.  56). 


Furicubr  artery. 


Funicular  vein. 
Wharton's  jelly. 
Amnion. 


Fig.  52. — Transverse  section  of  the  cord. 

As  anomalies,  I  may  note  the  absence  of  one   artery,  or  the 
presence  of  a  third.    Exceptionally,  there  may  be  two  or  three  veins. 


Fir,.  53. 


Fig.  54 


Fig.  5: 


Fig.  56. 


In  the  interior  of  the  vesseis  are  found  incomplete  semilunar 
valves,  which  sometimes  become  circular,  like  a  diaphragm.  The 
physiological  role  of  these  valves  is  not  well  known,  and  beside, 
must  be  of  slight  importance,  since  the  obstruction  they  produce  is 
incomplete.     They  may  play  a  certain  part  in  the  production  of  the 


56  Development  and  Description  of  the  Human  Orum. 

funicular  souffle.  The  existence  of  fine  vessels  in  the  cord,  the  rasa 
propria  (Paige),  has  been  note:l;  the  existence  of  lymphatics  and 
nerves  has  not  been  proven. 

Physiology. — The  cord  serves  to  unite  the  mother  and  the  foetus, 
through  the  intermediate  placenta.  The  blood  carried  to  the  pla- 
centa by  the  umbilical  arteries  is  returned  to  the  fcetus  by  the 
umbilical  vein,  after  having  undergone  respiratory  and  nutritive 
modifications  in  the  placenta.  Contrary  to  the  usual  purposes  of 
these  vessels,  it  will  be  observed  that  here  the  arteries  carry  the 
dark  blood  and  the  vein  the  red  blood. 

III.  Embryonic  portion  of  the  ovum. — The  foetus  at  term. 
— There  is  no  positive  sign  that  will  permit  us  to  affirm  that  the 
fcetus  is  at  term  ;  thus  we  are  obliged,  for  this  determination,  to  use 
a  series  of  points  which,  as  a  whole,  afford  some  certainty.  The 
points  are  : 

1.  The  information  furnished  by  the  mother,  on  the  subject  of 
the  probable  duration  of  the  pregnancy,  at  the  moment  of  delivery 
(last  menstruation,  a  single  coitus,  first  movements  of  the  fcetus  . 

2.  The  weight  of  the  child,  which  is,  on  the  average,  three  kilo- 
grammes, attaining  quite  often  three  thousand  five  hundred  grammes, 
but  the  variations  from  greater  to  less  may  be  considerable — max- 
imum nine  thousand  grammes  (Eiembault) ;  minimum,  one 
thousand  three  hundred  grammes  (Blot) .  It  must  al so  be  understood 
that  this  inferior  limit  is  somewhat  arbitrary,  in  the  default  of  exact 
knowledge  of  the  date  of  conception. 

3.  The  length  of  the  foetus,  measured  from  head  to  foot,  is 
generally  fifty  centimetres — equal  to  that  of  the  umbilical  cord. 
Variations  of  five  centimetres,  more  or  less,  are  not  rare. 

4.  The  development  of  the  nails  and  hair  is  too  variable  to  be 
taken  into  serious  consideration.  In  general,  in  the  fcetus  at  term, 
the  nails  exceed  the  extremity  of  the  finger.  The  hair  presents  a 
length  of  two  to  three  centimetres,  or  even  more,  and  the  fine  down 
which  covers  all  the  hairy  regions  appears  more  developed  before 
term  than  at  term. 

5.  In  the  male  infant  the  testicles  have  descended  into  the 
scrotum,  but  this  descent  sometimes  occurs  before  term,  and  does 
not  always  exist  at  term. 

G.  The  ossification  of  the  skull,  the  only  bones  that  can  easily  be 
explored  in  the  living  child,  is  too  variable  in  its  degree  to  afford 
clear  information.  In  the  dead  fcetus  there  may  be  recognized  in 
a  section  of  the  inferior  part  of  the  femur  a  point  of  ossification 
that  Beclard  considers  a  positive  sign  of  the  maturity  of  the  fcetus. 
The  researches  of  Hecker  and  of  Hartman  have  shown,  however, 
that  it  sometimes  exists  before  term,  and  that  it  may  be  wanting 


Development  and  Description  oj  the  Human  Ovum.  57 

;it  term.  No  one  of  these  signs  is  positive,  then,  but  their  recog- 
nition permits  an  approximate  valuation,  generally  sufficient  to 
d(  termine  it'  the  child  is  at  lull  term. 

Form  and  topography. — The   general    form  of  the   foetus,  rolled 
up  in  the  cavity  of  the  uterus,  is  ovoid  i  Fig.  58),  th<  large  extremity 
corresponding  to  the  breech  and  the  small  to  the  head.     This  is  the 
.atic  ovoid. 


Fig.  57. — Beclard's  point  cf  ossification.  Fig.  5S. — Somatic  ovoid. 

The  somatic  ovoid  may  he  divided  into  two  secondary  ovoids : 
Cephalic  (head),  cormic  (trunk).     These  are  united  by  the  neck. 

The  topography  of  the  cormic  ovoid  needs  no  special  consider- 
ation ;  the  foetal  trunk  is  identical,  with  smaller  dimensions,  with 
that  of  the  adult;  it  is  an  adult  in  miniature. 

This  is  not  true  with  regard  to  the  cephalic  ovoid.  In  exploring 
the  head  of  the  new-born,  the  union  of  the  bones  which  compose  it 
is  found.  These  are  real  solutions  of  continuity  (sutures  and  fonta- 
nelles)  that  are  of  considerable  importance  in  obstetrics,  for  a 
knowledge  of  them  permits  diagnostication  of  the  situation  and  the 
relations  of  the  cephalic  extremity  which  presents  during  delivery. 

The  sutures  are  the  lines  of  union  of  two  contiguous  bones  and 
the  fontanelles  are  the  confluents  formed  by  the  meeting  of  two  or 
more  sutures. 

The  fontanelles  are  two,  principal  or  median;  and  two,  secondary 
or  lateral. 

The  two  median  fontanelles  are  : 

1.  The  lambda,  or  the  posterior  fontanelle  (small  fontanelle),  at  the 
union  of  the  occipital  and  the  two  parietal  bones,  a  virtual  fonta- 
nelle, for  the  1  Mines  do  not  leave  a  free  space  at  this  point. 

•2.  The  bregma,  or  anterior  fontanelle  (great  fontanelle),  at  the 
union  of  the  parietal  and  the  frontal  bones,  a  real  fontanelle,  con- 
stituted by  a  large  fibrous  space,  having  the  form  of  a  lozenge,  the 


58 


Development  and  Description  of  the  Human  Ovum. 


frontal  borders  being  more  prolonged  than  the  parietal.     This  fonta- 
nelle  generally  closes  two  or  three  months  after  birth. 
The  two  secondary,  or  lateral,  are : 

1.  Asterion,  at  the  union  of  the  occipital,  the  parietal 'and  the 
temporal  bones,  a  virtual  fontanelle. 

2.  The  pterion,  at  the  union  of  the  frontal,  the  parietal  and  the 
temporal  bones  and  the  great  wing  of  the  spenoid,  likewise  a  virtual 
fontaneDe  and  only  of  slight  importance. 


Fig.  59. — View  of  the  upper  part  of  the  head. 

Finally,  there  exist,  as  anomalies  and  consequently  as  accessory, 
two  other  median  fontanelles : 

1.  The  obelion,  a  lozenge-shaped  space,  at  one  or  two  centimetres 
in  advance  of  the  lambda  on  the  biparietal  suture. 

2.  The  glabella,  a  fibrous  median  space,  of  oval  form,  sometimes 
found  on  the  bifrontal  suture  at  about  two  centimetres  from  the 
root  of  the  nose. 


Fig.  60. — Lateral  view  of  the  head. 

The  sutures  are  named  from  the  bones  which  enter  into  their  for- 
mation.    These  we  find  : 

1.    The   biparietal   suture,  which,  beginning  at  the  occiput,  is 


Development  and  Description  of  tin   Human  Ovum.  59 

continuous,  after  traversing  the  I  regma,  with  the  bifrontal  Buture. 
These  two  Buturee  together  are  designated  as  the  sagittal  Buture. 

2.  The  occipito-parietal   Buture,  also  called    the  lamdoid,  on 
account  of  its  analogy  with  the  Greek  letter  of  the  same  name. 

3.  Tlu'  Eronto-parietal  sutuiv,  which  cuts  the  Bagittal  perpendicn? 
larly  and  terminates  laterally  in  the  pterion. 

4.  The  temporo-parietal  suture  unites  the  squamous  portion  of 
the  temporal  to  the  parietal. 


UT  >* 


0  C   C.    I    P 

Fig.  6i. — Cephalic  planisphere. 

The  other  sutures  present  only  a  secondary  importance  and  do 
not  merit  especial  mention.  In  the  track  of  these  sutures,  in  par- 
ticular the  biparietal  suture  toward  its  posterior  portion,  there  exi~t 
some  separate  hones,  more  or  less  disfiguring  the  topography  and 
interfering  with  the  diagnosis. 


60  Development  and  Description  of  the  Human  ^uro. 

Diameters. — If  the  two  foetal  ovoids  were  regular,  it  would  be  suf- 
ficient to  take  the  length  and  the  width  to  recognize  the  exact 
dimensions,  but  their  irregularities  necessitate  the  determination  of 
a  certain  number  of  diameters,  with  which  the  physician  should  be 
familiar  if  he  wishes  to  comprehend  the  mechanism  and  the  diffi- 
culties of  delivery.  Let  us  study  successively  the  two  ovoids,  the 
cephalic  and  the  corinie. 

A.  The  cephalic  ovoid.— The  foetal  head  is  composed  of  two  parts 
that  are  essentially  different :  One  forms  an  irregular  plane,  a  solid 
osseous  mass,  extending  from  the  occiput  to  the  face,  this  is  the 
base  of  the  cranium.  The  other  constitutes  a  case  enclosing  the 
brain  and  surmounting  the  base,  with  which  it  is  continuous  by  its 
base,  this  is  the  vault  of  the  cranium.  The  vault  is  of  predominant 
importance  in  normal  delivery  and  in  dystocia,  when  perforation 
and  crushing  are  not  necessary  but  when  the  cerebral  substance 
must  be  evacuated  to  reduce  the  head ;  the  base,  on  the  contrary, 
opposes  the  obstacle  to  delivery.  Thus  is  seen  the  different  roles 
of  these  two  portions  of  the  head  and  the  necessity  of  measuring 
their  principal  diameters. 

The  vault  of  the  cranium,  that  is,  the  intact  head,  has  three 
principal  diameters : 

1.  The  mento-maximum,  extending  from  the  point  of  the  chin  to 
the  most  distant  point  of  the  sagittal  suture,  at  some  millimetres  in 
front  of  the  lambda. 

2.  The  biparietal,  joining  the  two  parietal  protuberances. 

3.  The  bitemporal,  extending  from  one  pterion  to  the  other. 
The  base  of  the  cranium  has  also  three  principal  diameters : 

1.  The  inio-nasal,  which  extends  from  the  inion  to  the  root  of  the 
nose. 

2.  The  bimalar,  uniting  the  two  malar  tuberosities. 

3.  The  biosteric,  extending  from  the  asterion  to  that  of  the  oppo- 
site side. 

Aside  from  these  diameters,  which  are  to  a  certain  extent  static, 
there  are  others,  of  an  importance  only  comprehended  after  the 
study  of  the  mechanism  of  delivery,  which  may  be  called  dynamic. 
I  will  only  simply  mention  them  here,  returning  later  to  their  study 
apropos  of  parturition.     These  are  : 

1.  The  suboccipito-bregmatic,  extending  from  the  union  of  the 
occiput  and  the  neck  to  the  center  of  the  bregma. 

2.  The  suboccipito-maximum,  from  the  same  posterior  point  to 
the  most  distant  part  of  the  bifrontal  suture. 

:!.  The  Bubmento-bregmatic,  from  the  union  of  the  chin  and  the 
neck  to  the  center  of  the  bregma. 

I.  Submento-maximum,  from  the  same  anterior  point  to  the 
most  distant  part  of  the  sagittal  suture. 


Inj.nn  at   and    1 1'    •rijitifii   n/'  tl/r    Jliimnii    drum.  61 

The  ilimei  t  these  different  din  meters  nre  as  follows: 

Static  diauirtcrg. —  MR 

wii|^»rn$xin*m,  \y/z  centimetres, 
rlnionasafe*  ■)£  centimetres. 
5  centimetres. 
y^  centimetres, 
centimetres. 
byz  centimetres. 

Dynamic  diameters, — 

SuboccijJftb-bregmatic,  g]/2  centimetres. 
Suboccipito-maximum,  10^  centimetres. 
Suhmento-hregmatic,  <)l/2  centimetres. 
Submento-maximum  n  centimetres. 

For  the  Inst,  1(H  could  be  admitted,  but  it  is  important  to  know 
that  it  is  greater  than  the  Buboccipito-maximum,  and  we  would 

thru  have  a  series  of  figures  easily  retained,  6£,  11,  HI,  Ul,  10$,  11J, 
18J,  from  6  to  18,  with  the  exception  of  12,  by  adding  a  half  to  each. 
The  mento-maximum  and  the  inio-nasal,  as  well  as  the  dynamic 
diameters,  are  antero-posterior,  the  others  are  transverse. 

B.  Thr  ennui <■  <>n nd. — The  trunk  of  the  foetus,  much  more  irregular 
and  more  reducible  than  the  head,  also  presents  several  diameters, 
which  are,  on  account  of  its  compressibility,  only  of  secondary 
importance.     I  will  only  note : 

1.  The  bitrochanteric,  uniting  the  two  trochanters. 

2.  The  pubo-sacral,  extending  from  the  upper  part  of  the  sacral 
promoting  to  the  middle  of  the  anterior  surface  of  the  pubes. 

8.  The  bisacromial,  from  the  acromion  of  one  side  to  that  of  the 
opposite  side. 

4.  The  sterno-dorsal,  a  horizontal  line  from  the  middle  of  the 
sternum  to  the  corresponding  spinous  apophysis. 

The  diameters  measure  on  the  average  : 

Pubo-sacral,  6  centimetres. 
Bitrochanteric,  9  centimetres. 
Sterno-dorsal,  9  centimetres. 
Bisacromial,  12  centimetres. 

Figures  6,  9,  12  are  easily  retained. 

According  to  these  dimensions  one  would  be  led  to  believe  that 
the  thorax  forms  the  large  extremity  of  the  cormic  ovoid  and  the 
breech  the  smaller  portion,  but  the  two  diameters  of  the  breech  are 
much  less  reducible  than  those  of  the  thorax  and  the  addition  to  the 
pelvis  cf  the  lower  limbs  folded  on  themselves  considerably  increases 
the  volume  of  this  foetal  part  and  renders  it  really  larger  than  the 
thoracic. 

Physiology.  —  A.  Circulation.  —  The  foetus  presents  two  distinct 
circulations  during  its  sojourn  in  the  uterine  cavity.  The  first 
(embryonic),  depending  on  the  umbilical  vesicle \  the  second  (foetal), 
developing  with  the  allantoid  vesicle  and  replacing  the  preceding, 
this  is  the  placental  circulation. 


62 


Development  and  Description  of  the  Human  Oram. 


The  foetal  circulation  (Fig.  62)  differs  from  the  definitive  in  two 
essential  points:  1.  By  the  existence  of  a  funicular  placental 
territory,  which  brings  the  fcetal  blood  in  contact  with  the  maternal. 


Placenla 
Fig.  62. — Sehema  of  the  foetal  circulation. 


2.  By  the  communication  of  the  aortic  with  pulmonary  circulation 
in  two  ways  :  a,  through  the  foramen  ovale  (Fig.  62  B),  which  con- 
nects the  two  auricles;  b,  the  ductus  arteriosus,  uniting  the  pul- 
monary artery  and  the  aorta.     These  communications,  which  are 


Development  and  Description  oj  the  Human  (hum.  03 

destined  fco  disappear  at  birth,  permit  the  blood  to  make  the  com- 
plete round  of  the  circulation  without  passing  through  the  Lungs, 
and  these  structures  remain  rudimentary  tiuring  intrauterine  life. 

B.  Respiration. — This  function  comprises  three  successive  pro- 
cesses: 1.  The  oxygenation  of  the  blood,  accompanied  by  the 
elimination  of  carbonic  acid.  ^.  The  transportation  of  oxygen  to 
the  different  tissues  of  the  organism  by  the  intermediatory  circu- 
lation. :>.  The  deoxygenation  of  the  blood,  with  combustion  as  its 
result.  The  last  two  processes  are  only  present  in  the  foetus  to  a 
small  degree.  The  first  process  is  essentially  different  from  that 
of  the  adult  by  occurring  in  the  placenta  instead  of  in  the  lung.  In 
passing  through  the  placenta  the  foetal  blood  absorbs  oxygen  from 
the  maternal  circulation  and  discharges  its  carbonic  acid.  Every 
cause  of  arrest  of  the  placental  circulation,  of  partial  or  total  sup- 
pression of  the  function  of  the  placenta,  leads  to  asphyxia  of  the 
foetus. 

C.  Nutrition. — The  nutrition  of  the  foetus  is  carried  on  both  by 
the  blood  and  liquor  amnii.  In  the  placenta  the  blood  is  charged 
with  the  nutritive  elements  contained  in  the  maternal  circulation, 
for  the  placenta  permits  the  nitration  of  solid,  liquid  and  gaseous 
elements.  The  nutritive  role  of  the  amniotic  liquid  is  not  so  well 
established  as  that  of  the  blood.  It  possesses  nutritive  qualities 
for  it  contains  albumin  and  salts.  It  is  swallowed  by  the  foetus, 
for  experiments  on  animals  by  freezing  have  shown  the  existence 
of  ice  extending  from  the  amniotic  liquid  through  the  mouth  and 
oesophagus  to  the  stomach.  Examination  of  the  meconium  under 
the  microscope  has  also  shown  the  existence  of  numerous  hairs  from 
the  skin,  which  could  only  be  drawn  in  with  the  liquor  amnii.  But 
nutrition  exists  in  monstrosities  in  which  the  mouth  is  absent  and 
also  in  the  early  months  of  intrauterine  life  when  deglutition  is  im- 
possible, so  that  if  the  liquor  amnii  fulfills  any  nutritive  purpose 
at  all  it  is  very  slight  compared  with  that  of  the  placenta. 

D.  Secretions. — The  skin  furnishes  the  vernix  caseosa  which  at  the 
moment  of  birth  covers  the  foetus  like  an  irregular  false  membrane. 

The  intestine  secretes  the  meconium,  a  mixture  of  bile,  cellular 
debris  and  different  elements  found  in  the  liquor  amnii.  Except 
under  special  conditions,  the  meconium  is  only  expelled  after  birth. 

The  kidneys  also  act  during  pregnancy.  The  urine  accumulates 
in  the  bladder,  and  then  passes  into  the  liquor  amnii.  Obliteration 
of  one  of  the  ureters  produces  hydronephrosis,  and  that  of  the 
urethra,  retention  of  urine  with  distention  of  the  bladder — a  proof 
of  the  existence  of  micturition  during  infra-uterine  life. 

E.  Innervation  and  motility. — Sensibility  and  motility  exist  in  the 
foetus,  every  excitation  conveyed  to  it  is  interpreted  by  movements. 
It  is  also  probable  that  during  intra-uterine  life  there  are  alternatives 
of  sleeping  and  waking. 


64  Modifications  of  the  Maternal  Organism. 


CHAPTER  III. 


MODIFICATIONS   OF   THE   MATERNAL 
ORGANISM. 

We  have  studied  the  ovum  during  its  development  in  the  uterine 
cavity,  it  is  now  important  to  study  the  parallel  modifications  which 
occur  in  the  maternal  organism.  These  modifications  are  not 
localized,  as  might  be  supposed,  in  the  genital  system,  but  involve 
the  whole  economy.  It  will  then  be  necessary  to  successively  examine 
all  the  systems.  I  shall  begin  with  the  genital  apparatus  as  the  one 
most  directly  interested. 

I.  Genital  system  and  vicinity. — Some  special  anatomical  consider- 
ations are  necessary  to  a  proper  understanding  of  this  subject. 

The  uterus  is  the  organ  in  which  the  ovum  is  developed  during 
normal  pregnancy.  Situated  in  the  pelvic  cavity,  with  the  rectum 
behind  and  the  bladder  in  front,  it  unites  the  vagina  to  the  tubes. 

The  general  form  of  the  uterus  is  that  of  a  pear,  the  large  ex- 
tremity constituting  the  body,  the  small  the  cervix.  The  body  and 
the  cervix  are  united  by  a  thinner  part,  the  isthmus.  In  the 
normal  state  the  axis  of  the  uterus  is  rectilinear,  that  is,  the  body 
and  the  cervix  have  the  same  direction.  This  uterine  axis  is  nearly 
identical  with  that  of  the  superior  strait  and  is  perpendicular  to 
that  of  the  vagina.  However,  the  axis  of  the  uterus  is  perpendicular 
to  that  of  the  vagina  only  when  there  is  a  certain  degree  of  repletion 
of  the  bladder.  But,  after  the  evacuation  of  the  urine,  ante-devi- 
ation occurs.  Thus  the  uterus  lies  on  a  cushion  of  water  and  fol- 
lows its  variations.  The  uterus  is  held  in  its  normal  position  by 
by  the  support  given  to  it  by  the  pelvic  floor. 

The  longitudinal  dimension  of  the  uterus  is  six  centimetres  and 
a  half,  which  is  divided  as  follows  : 

Cervix, 0,025 

Isthmus, 0,005 

Body,  cavity,        ....  0,025 

Thickness  of  the  wall,  -         -  0,010 


0,065 

These  dimensions  represent  the  average  as  applied  to  all  uteri. 
It  should  not  be  forgotten,  however,  that  in  the  nulliparous  woman 
the  cavity  of  the  cervix  is  greater,  and  in  the  multiparous  that  of 
the  body. 

Weight:  forty  grammes. 

The  uterus  is  covered  by  the  peritoneum  in  the  greatest  part  of 
its  extent  except  over  the  three  regions  shown  in  Fig.  65.     This 


Modifications  of  t)u   Maternal  Organism, 


65 


membrane  separates  it  from  the  bladder  in  front,  from  the  in- 
testines above  and  from  the  rectum  behind.  The  fundus  of  the 
uterus  is  situated  about  three  centimetres  above  the  horizontal  plane 
passing  through  the  superior  portion  of  the  symphysis  pubis. 

I  have  already  described  the  interior  of  the  uterus  under  head  of 
menstruation  audit  is  sufficient  to  say  here  that  the  external  orifice 
is  rounded  and  sometimes  punctiform  in  the  nulliparous  woman, 
that  it  is  transversely  elongated  after  a  first  parturition,  and  that, 
in  consequence  of  multiple  lacerations,  it  may  have  a  stellate  or  an 
irregular  appearance. 


Uterine  mucosa. 
Cavity  of  the  body. 

Isthmus. 

Arbor  vitae. 

Branches  of  arbor  vitas. 

Vaginal  cul-de-sac. 
Vagina. 
Fig.  63. — Vertical  and  transverse  section  of  the  uterus. 

The  uterus  is  composed  of  an  important  muscular  coat,  ineom= 
pletely  covered  by  a  serous  membrane,  and  lined  on  its  interior  by 
a  mucous  covering  that  we  have  already  studied.  The  muscular 
tunic  is  exclusively  composed  of  non-striated  fibres.  It  differs  in 
the  body,  in  the  isthmus  and  in  the  cervix. 

Body. — Fig.  67  schematically  represents  this  structure.  In  the 
center,  forming  the  framework,  is  a  plexiform  layer  formed  by  inter- 
lacing muscular  fibres  with  the  meshes  occupied  by  the  arteries  and 
the  veins  which  dilate  during  pregnancy  to  form  veritable  sinus  -. 
Above  this  plexiform  layer  is  the  superficial  muscular  layer  com- 
prising an  antero-posterior  loop,  which,  commencing  at  the  isthmus 
in  front,  follows  the  median  line  of  the  uterus  to  terminate  behind 
at  a  corresponding  point.  Then  there  comes  a  series  of  transvi  - 
fibres,  which  are  prolonged  in  part  into  the  broad  ligaments.  Be- 
neath is  the  deep  muscular  layer,  also  comprising  two  arrangements 


Modifications  of  the  Maternal  Organism. 


Fig.  64. — Anteroposterior  and  median  section  of  the  female  pelvis. 


Fig.  65. — Profile  view  of  the  uterus. 


Fig.  66. — Relations  of  the  cervix 

(Schroeder). 


Modifications  of  the  Maternal  Organism. 


67 


of  fibres;  one  transverse,  forming  a  series  of  irregular  rings,  the 
others  in  the  form  of  a  X.  This  series  of  fibres  in  the  form  of  a  Z 
are  directly  in  contact  with  the  mucosa. 


Deep  layer,  transverse  fibres, 
Fibers  in  Z,  vertical  part 

Fibers  in  Z,  inclined  part 


Superficial  layer,  vertical  fibres. 
Superficial  layer,  transverse  fibres. 
Plexiform  or  middle  layer. 


Fig.  67. — Transverse  section  of  the  uterus,  at  the  level  of  the  body  (schema). 

Isthmus. — In  the  isthmus  we  only  find  transverse  or  slightly 
oblique  fibres,  that  is,  the  plexiform  layer  does  not  reach  here,  hut 
only  the  superficial  loop  fibres  and  those  in  the  form  of  a  Z. 

Cervix. — The  same  is  true  of  the  cervix,  but  there  is,  however, 
difference  between  the  isthmus  and  the  cervix,  as  in  the  latter  the 
connective  tissue  element  predominates  while  in  the  isthmus  the 
muscular  fibres  are  more  abundant. 

These  anatomical  considerations  permit  us  to  pass  to  the  study 
of  the  modifications  of  the  uterus  under  the  influence  of  pregnancy. 
These  modifications  are  of  three  kinds: 

A.  Macroscopic. 

B.  Microscopic. 

C.  Physiological. 

A.  Macroscopic  modifications, — The  body  containing  the  ovum 
and  the  cervix  opposing  its  egress,  assume  a  physiological  role 
essentially  different.     The  modifications  of  these  two  parts  of  the 


68 


Modifications  of  the  Maternal  Organism. 


uterus  are  completely  dissimilar,  from  which,  arises  the  necessity 
of  studying  them  separately. 

1.  Modifications  of  the  body. — Volume. — I  shall  only  speak  of  the 
vertical  diameter,  which  measures  fourteen  centimetres  at  the 
third  mouth  (not  including  the  cervix) ;  twenty-one  in  the  sixth 
month,  and  thirty-five  in  the  ninth  month. 


Fig.  68. 

Uterus  empty 
(profile  view). 


Fig.  69. 

First   three  months 

of  pregnancy 

(uterus  rounded). 


Fig.  70. 

Second 

three  months  of 

pregnancy. 


Fig.  71. 

Third  three  months 
of  pregnancy. 


Fig.  72. 

First  three  months. 

Uterus  in  pelvis 

(front  view). 


Fig.  73. 

Second 

three  months. 

Uterus  in  abdomen. 


Fig.  74. 

Third  three  months, 

Abdominal-pelvic 

situation. 


Cajiacity. — The  capacity  of  two  to  three  cuhic  centimetres  in  an 
empty  state  is  increased  to  four  or  five  litres. 

Form. — The  uterus  hecomes  rounded  during  the  first  three  months 
ot  pregnancy,  while  increasing  in  volume.  During  the  second  three 
months,  the  uterus  especially  increases  in  its  postero-superior  part, 
in  the  region  indicated  in  Fig.  70,  by  a  series  of  small  projections, 
in  such  a  manner  that  the  openings  of  the  tubes  are  carried  below 
and  a  little  forward.  During  the  last  three  months  it  is  especially 
the  antero-inf  erior  part  which  develops,  in  such  a  way  that  the 
cervix  is  thrown  backward.  The  general  form  of  the  uterus  at 
term  is,  as  before  pregnancy,  that  of  an  ovoid  with  the  small  ex- 
tremity downward. 


Modifications  oj  tht  Maternal  Organism.  69 

Situation. — During  the  first  three  months  of  gestation  the  uterus 
is  developed  in  the  interior  of  the  pelvic  excavation.  The  fundus 
passes  tho  superior  strait  and  encroaches  on  the  abdominal  cavity 
(Fig.  71). 

In  the  second  three  months  the  uterus,  becoming  too  large  for 
the  pelvic  cavity,  ascends  into  the  abdominal  cavity  above  the 
superior  straight  (Fig.  78). 


Umbilicus,  middle  of 
pregnancy. 


Fig.  75. — Gradual  elevation  of  the  uterus  in  the  abdominal  cavity. 

During  the  last  three  months  the  situation  of  the  uterus  varies  in 
the  primiparse  and  in  the  multiparas.     In  the  .primiparse,  early 

descent  of  the  uterus  into  the  pelvic  excavation,  with  engagement 
of  the  festal  part,  takes  place,  especially  during  the  last  two  months 
l  Fig.  74).  In  the  multipara-  the  lax  abdominal  Avail  allows 
sufficient  room  for  the  distention  of  the  uterus,  and  engagement 
only  occurs  during  the  last  fifteen  days  of  pregnancy,  sometimes 
even  later. 

The  relation  of  the  fundus  of  the  uterus  to  the  abdominal 
wall  (Fig.  75)  is  interesting  to  determine,  for  it  serves  as  a  mark 
from  which  an  approximate  estimation  of  the  date  of  the  pregnancy 


70  Modifications  of  the  Maternal  Organism. 

may  be  made.  Unfortunately,  great  variations  exist.  However, 
it  may  be  said  in  a  general  way  that : 

During  the  fourth  month  the  uterus  is  a  little  below  the  um- 
bilicus; during  the  fifth,  at  the  level  of  the  umbilicus.;  during  the 
sixth,  a  little  above  the  umbilicus ;  during  the  seventh,  three 
fingers'  breadth  above  the  umbilicus ;  during  the  eighth,  six  fingers' 
breadth  above  the  umbilicus,  and  during  the  ninth  month,  nine 
fingers'  breadth  above. 

Orientation. — The  uterus  presents  three  principal  axes,  an  antero- 
posterior, a  vertical,  and  a  transverse.  Now,  during  pregnancy,  it 
may  undergo  various  deviations  by  turning  on  these  axes. 

1  Antero-posterior  axis. — Lateral  inclination. — I  suppose  this  axis 
passing  in  the  vicinity  of  the  cervix.  Movements  of  the  uterus 
around  this  fictitious  line  incline  its  fundus  to  the  right  or  to  the 
left.  From  the  statistics  of  one  hundred  cases  I  have  deduced  the 
following : 

Right  inclination,  55  per  100. 
Left  inclination,  5  per  100. 
No  inclination,  40  per  100. 


Fig.  76. — Median  uterus,  symmetrical  Fig.  77. — Apparent  inclination  of  the 

development  of  the  two  halves  of  the       uterus,  asymmetrical  development  of  the 
organ.  of  the  two  halves  of  the  organ. 

Various  causes  have  been  invoked  to  explain  this  lateral  incli- 
nation of  the  uterus;  among  them  are  :  Decubitus,  preponderant 
usage  of  the  right  or  of  the  left  arm,  the  situation  of  the  placenta, 
the  relative  length  of  the  round  ligaments,  the  anatomical  dispo- 
sition of  the  mesentary,  and  vesical  or  rectal  repletion.  But  none 
of  these  explanations  are  satisfactory,  and  it  seems  the  mode  cf 
development  of  the  uterus,  either  symmetrical  or  asymmetrical, 
affords  a  better  account  of  these  lateral  deviations.  The  sym- 
metrical development  of  the  two  halves  of  the  organ  gives  a  uterus 
which  appears  median  (Fig.  76),  while  asymmetrical  development 
imposes  a  right  (Fig. 77) or  a  left  inclination.  Thus  the  inclination 
of  the  uterus  is  apparent  and  not  real.  If  real  inclination  occur, 
it  is  consecutive  to  the  preceding. 


Modifications  of  the  Maternal  Organism. 


71 


2.  Vertical  axis. — Rotation  is  the  movement  round  the  vertical 
axis.  The  anterior  Burface  of  the  uterus  is  generally  inclined  to- 
ward the  Bide  where  the  organ  is  most  developed.     This  rotation  is 

important  with  regard  to  a  Casarian  operation,  for  if  the  direction 
is  not  corrected  there  is  danger  of  wounding  some  important  vessels. 


Fig.  7S. — Normal  gravid  abdomen.        Fig.  79. — Pendulous  gravid  abdomen. 

3.  Transverse  axis. — Antero-posterior  inclination. — I  suppose  this 
axis  passing  through  the  union  of  the  body  and  cervix.  During 
the  first  three  months,  rarely  later,  the  body  of  the  uterus  may  in- 
cline backward,  thus  constituting  retroversion  of  the  gravid  uterus, 
which  we  shall  study  further  on.  During  the  latter  part  of  preg- 
nancy this  posterior  deviation  is  impossible,  on  account  of  the  size 
of  the  uterus,  but  anteversion  may  occur  with  a  very  lax  abdominal 
wall  (Fig.  79). 

Weight. — Thickness. —  The  weight  of  the  uterus  attains  about  a 
kilogramme  at  term  (not  including  the  foetus).  The  thickness  of 
the  uterus  is,  normally,  rive  millimetres.  Opinions  on  this  subject 
differ  greatly.  Some  authorities  say  it  is  thinner,  some  that  it  is 
thicker,  and  some  that  it  remains  the  same  during  pregnancy, 
and.  all  have  autopsies  to  bear  them  out.  These  different  obser- 
vations demonstrate  the  inconsistency  of  its  thickness.  There  exists 
in  general  a  notable  difference  between  the  superior  segment  and 
the  inferior,  the  latter  being  relatively  very  thin.  Points  of  the 
uterus  which  have  supported  a  prolonged  compression,  like  that  of 
the  foetal  head,  are  diminished  in  thickness.  The  surface  of  the 
insertion  of  the  placenta  is  hypertrophied,  on  the  contrary. 

2.  Modifications  of  the  cervix. — The  cervix  is  modified  in  its  form, 
in  its  situation,  in  its  volume  and  in  its  consistence.  The  effaee- 
ment,  that  is,  the  disappearance  of  the  cervix  which  precedes  the 


72 


Modifications  of  the  Maternal  Organism. 


opening  of  the  external  orifice,  although  sometimes  occurring  during 
pregnancy,  will  be  studied  with  accouchement. 


Fig.  80. 


Type  norm&f 


Fig.  Si- 


Fig.  82. 


Fig.  83. 


a,  uterine  circle  (Bandl's  ring)  limit  between  the  supero- lateral  and  inferior 
segments;  b,  internal  orifice;  c,  external  orifice. 

Form. — Outside  the  modifications  of  form  caused  by  effacement 
there  may  be  found,  aside  from  the  normal  type  often  persisting  in 
the  primiparse,  one  of  the  three  principal  forms  represented  in  the 
adjoined  schema  (Figs.  80,  81,  82  and  83).  These  modifications 
;i  re  due  to  the  degree  of  the  relative  dilatation  of  the  two  orifices  of 
the  uterus. 

Situation. — The  cervix  naturally  follows  the  body  in  its  evolutions. 
During  the  first  three  months  the  cervix  is  found  in  its  natural 
position,  often  a  little  approached  to  the  perinaeum.  During  the 
■ml  three  months  the  cervix  follows  the  uterus  in  its  ascent  and 
becomes  less  accessible  to  vaginal  touch.  During  the  last  three 
month-  it-  situation  differs  in  the  primipara  from  that  in  the  multi- 
para.    In  consequence  of  the  progressive  engagement  during  the 


Modifications  of  the  Maternal  Organism. 


73 


last  three  months  in  the  primipara,  the  cervix  descends  and  is  also 

usually  deviated  to  the  left  and  a  little  haekward.  Rarely  the  cervix 
is  median  or  to  the  right.  In  the  multipara,  engagement  takes 
place  later,  and  the  situation  of  the  cervix  varies  with  degree  of  the 
uterine  descent.  With  regard  to  cervical  deviations,  they  are  the 
same  as  in  the  primiparee. 


FlGS.  84  and  85. — Folds  of  the  vagina  during  pregnancy. 


Fig.  S6. — Ligaments  of  the  uterus  seen  from  above. 


Volume. — Hypertrophy  of  the  cervix  is  generally  admitted,  under 
the  influence  of  pregnancy,  in  such  a  manner  that  its  length  is 
doubled ;  from  twenty-five  millimetres  it  is  increased  to  five  centi- 
metres.    We  shall  return  to  this  apropos  of  effacement. 


74  Modifications  of  the  Maternal  Organism. 

Consistence. — The  cervix  progressively  diminishes  in  consistence 
during  pregnancy.  This  softening  does  not  occur  as  a  whole,  but 
from  the  external  orifice  toward  the  internal,  fallowing  progressive 
invasion  like  that  of  an  epithelioma.  This  softening  is  sometimes 
so  great  that  the  examining  linger  can  scarcely  perceive  the  cervix 
in  the  midst  of  the  vaginal  tissues.  Attempts  have  been  made  to 
base  a  diagnosis  of  the  date  of  pregnancy  on  the  extent  of  the  soften- 
ing of  the  cervix,  but,  even  in  a  first  pregnancy,  the  variations  are 
too  great  to  allow  us  to  accord  this  sign  any  such  degree  of  precision. 
This  modification  is  probably  due  to  a  serous  infiltration  and  to 
microscopic  changes  occurring  in  the  cervix.  It  is  to  be  noted  that 
all  the  tissues  of  the  genital  zone,  and  in  particular  those  of  the 
vulva,  undergo  an  analogous  softening,  though  less  in  degree,  and 
equally  accompanied  by  hypertrophy. 

B.  Microscopic  modifications. — In  studying  the  development  of  the 
ovum  we  have  seen  the  modifications  of  the  uterine  mucosa  which  con- 
stitute the  decidua.  Only  the  mucous  membrane  of  the  body  and  of  the 
isthmus  undergo  this  transformation.  In  the  cervix  the  mucosa,  out- 
side of  functional  superactivity  and  epithelial  proliferation,  does  not 
present  any  change.  The  cervical  glands  secrete  a  viscous  liquid 
of  such  great  consistence  that  it  forms  a  veritable  obdurator,  a 
gelatinous  plug  which  is  cast  out  at  the  beginning  of  labor.  The  mus- 
cular fibres  undergo  modifications  of  hypertrophy  and  multipli- 
cation both  in  the  body  and  in  the  cervix  cf  the  uterus,  but  less  in 
degree  in  the  latter. 

The  peritonaeum  is  hypertrophied  and  enlarged  to  accommodate 
the  increase  in  the  surface  of  the  uterus.  The  afferent  arteries  of 
the  uterus  take  on  considerable  development,  sufficient  to  assure  a 
complete  supply  of  blood  to  the  organ.  The  veins  undergo  a  parallel 
development,  forming  true  sinuses  in  the  muscular  wall.  There 
is  an  analogous  increase  in  the  size  of  the  lymphatics.  The  nerves 
also  appear  hypertrophied. 

C.  Physiologiccd  modifications. — The  uterus  is  essentially  a  mus- 
cular organ  and  like  all  the  other  viscera  it  is  connected  with  the 
central  nervous  system  by  the  centrifugal  and  the  centripetal  nerves. 
The  presence  of  nerves  creates  two  properties,  sensibility  and  irri- 
tability. As  a  muscular  organ  the  uterus  possesses  extensibility, 
retractility  and  contractility.  These  five  physiological  properties 
are  more  or  less  modified  by  the  puerperal  state : 

1.  The  sensibility  of  the  uterus,  body  and  cervix,  is  obscure.  In 
the  normal  state  the  uterine  surface  can  be  attacked  without  causing 
acute  pain.  On  the  contrary,  in  the  pathological  state  this  suscepti- 
bility is  capable  of  arising  quickly.  Under  the  influence  of  uterine 
contraction  during  labor  the  pain  becomes  severe,  as  much  in  the 
cervix  as  in  the  body.     This  difference  in  the  results  produced  by 


Modifications  of  the  Maternal  Organism.  lij 

contact  and  by  contraction  justifies  the  special  nature  attributed  to 
uterine  sensibility. 
2.  The  uterus  is  irritable,  that  is  to  say  that  an  excitation  arising 

in  any  sensitive  zone  is  transmitted  to  the  uterus  reilexly  and  causes 
a  contraction.  The  majority  of  the  methods  employed  to  cause 
ahortion  act  by  bringing  this  property  of  the  uterus  into  play. 

8.  Extensibility  permits  the  uterus  to  distend  progressively  with 
the  development  of  the  product  of  conception.  Without  it  pregnancy 
would  be  impossible.  During  gestation  the  body  of  the  uterus 
undergoes  extension ;  at  the  moment  of  labor  the  cervix  and  the 
inferior  segment  are  extended  in  turn. 

4.  Retractility  is  opposed  to  extensibility.  By  this  property  the 
uterus  has  a  tendency  to  diminish  in  volume,  like  a  rubber  balloon. 
Retractility  is  only  the  effect  of  the  tonicity  possessed  by  the  uterus 
in  common  with  all  other  muscles.  Pathological  exaggeration  of 
retractility  produces  uterine  tetanus  and  its  absence  creates  uterine 
inertia. 

5.  Contractility  is  constituted  by  the  momentary  contraction  of 
the  uterus  as  a  whole.  It  results  in  a  diminution  of  the  capacity 
of  the  organ  or  in  a  tendency  to  this  diminution.  In  an  empty 
state  of  the  uterus  contractions  are  painless  and  are  not  felt  except 
in  pathological  conditions,  such  as  pseudo  membranous  dysmenor- 
rhoea.  During  pregnancy  they  are  also  painless,  and  if  they  are 
perceived  at  all  it  is  as  a  passing  hardness  of  the  abdomen.  On  the 
contrary,  contractions  become  painful  during  labor. 

II.  Vagina. — Vulva. — Perinceum. — These  structures  undergo  two 
principal  modifications,  hypertrophy  and  softening,  occurring  in 
common  with  the  same  changes  in  the  uterus,  thus  preparing  a 
favorable  condition  for  the  exit  of  the  child. 

A.  Vagina. — The  vagina  increases  in  all  its  dimensions.  Its 
elongation  facilitates,  in  the  second  three  months  of  pregnancy, 
the  ascension  of  the  uterus.  When,  during  the  last  three  months, 
the  uterus  descends  again  the  vagina,  is  folded  on  itself  (Figs.  84 
and  49).  The  vascular  system  undergoes  an  equal  development, 
having  the  double  effect  of  modifying  the  coloration  of  the  vagina 
and  of  making  the  arterial  pulsations  perceptible  in  some  cases 
(vaginal  pulse  of  Osiander). 

B.  Vulva. — Besides  hypertrophy  and  a  certain  degree  of  softening 
the  vulva  undergoes  two  other  important  modifications.  A  pigmen- 
tation analogous  to  that  of  the  breast  cr  of  the  face  and  a  violaceous 
coloration,  more  marked  on  as  the  vagina  is  approached. 

C.  Perinceum. — The  perina?um,  participating  in  the  softening  and 
in  the  hypertrophy  of  the  tissues  of  the  genital  zone,  acquires  under 


76 


Modifications  of  the  Maternal  Organism. 


the  influence  of  pregnancy  a  great  suppleness  permitting  stretching 
at  the  moment  of  accouchement.  Like  the  vulva,  it  often  becomes 
the  seat  of  pigmentation,  especially  in  brunettes. 


Fig.  87. — Ligaments  of  the  uterus,  profile  view.     A,  insertion  of  the  broad 
ligaments;  B,  utero-sacral  ligament;    C,  utero-vesical  ligament. 

III.  Appendages  of  the  uterus. — I  shall  study  the  modifications  of 
the  ligaments  with  the  enclosed  vessels,  by  describing  the  modifi- 
cations impressed  on  them  by  pregnancy. 

A.  Ligaments. — During  pregnancy  all  the  ligaments  undergo  a 
notable  hypertrophy  with  a  certain  degree  of  softening,  as  in  all  the 
organs  of  the  genital  zone.  The  suppleness  acquired  by  the  utero- 
sacral  ligaments  permit  the  ascension  of  the  cervix  during  the  second 
three  months  of  pregnancy.  With  regard  to  the  broad  ligaments, 
the  contraction  of  their  muscular  fibres  play,  according  to  the 
demonstrations  of  Thevenot  and  Budin,  an  important  role  in  the 
engagement  of  the  uterus  and  of  the  foetal  part.  Their  contraction, 
Bynergetic  with  the  pressure  exercised  by  the  abdominal  wall,  causes 
the  foetus  to  descend  into  the  excavation;  their  relaxation  permits 
the  ascension  of  the  uterus. 

The  tube  and  the  ovary,  contained  in  the  broad  ligament,  par- 
ticipate in  the  general  hypertrophy  of  the  genital  system.  The 
ovary  in  particular,  which  has  furnished  the  fecundated  vesicle, 
times  acquires  the  volume  of  a  small  walnut.  Budin  has 
justly  insisted  on  the  pain  which  is  often  caused  by  palpation  of 
the  ovaries  during  pregnancy. 

B.  Bloodvessels. — The  adjoined  plate  brings  these  structures  to 


Modifications  of  the  Maternal  Organism. 


77 


memory  sufficiently  without  necessitating  further  description.  All 
these  vessels,  especially  the  veins,  assume  a  considerable  develop- 
ment during  gestation. 


VEP 


VEINS. 


ARTERIES. 


Fig.  88. — Bloodvessels  of  the  genital  system.  AA, aorta;  R,  renal  artery ;  AUO, 
utero-ovarian  artery;  AIG,  left  primary  iliac  artery;  AP,  puerperal  artery;  AU, 
uterine  artery;  All,  internal  iliac  artery;  AIE,  external  iliac  artery;  AEP,  epi- 
gastric arteries;  ALR,  artery  of  the  round  ligament;  AV,  vaginal  artery;  OV, 
ovary;  TR,  tube;  V,  vagina;  UT,  uterus.  Veins:  corresponding  deviationi  on  the 
opposite  side. 

C.  Lymphatics. — The  role  of  the  lymphatics  is  small  in  the  physi- 
ological state,  but  is  more  important  in  cases  of  puerperal  septi- 
cemia. The  uterine  lymphatics  pass  to  a  series  of  glands  grouped 
in  the  pelvis,  as  indicated  in  Figure  89. 


IV.  Articulations  of  the  pelvis. — The  three  articulations  which  es- 
pecially fix  the  attention  are  the  two  sacro-iliac  symphyses  and  the 
symphysis  pubis.  As  a  whole,  they  may  be  considered  as  three 
breaks  in  the  pelvic  ring  which  give  it  greater  flexibility.     This 


78 


Modifications  of  the  Maternal  Organism. 


appears  to  be  their  special  use.  Under  the  influence  of  pregnancy 
the  peripheral  ligaments  of  these  articulation  relax,  and  the  intra- 
articular ligaments  undergo  a  certain  degree  of  softening  with 
hypertrophy.  These  modifications  cause  a  slight  separation  of  the 
articular  surfaces. 


-   _      Guerin's   retro-pubic 
glands. 


Satellite  glands  of  the 
uterus. 

Uterus. 


Lateral  pelvic  glands. 
Sacral  glands. 


— Lymphatic  glands  of  the  pelvis. 


V.  Abdominal  wall. — The  umbilicus  seems  deeper  during  the  first 
three  months  of  pregnancy,  as  if  the  urachus  exercised  traction  at 
this  point.  Beginning  with  the  second  three  months  the  umbilicus 
is  progressively  flattened  and  often  becomes  projecting  in  the  last 
three  months.  These  three  periods  of  the  changes  in  the  umbilicus 
have  only  a  theoretical  interest. 


Fig.  90  — Linese  alblcantes  of  pregnancy. 

The  abdominal  integument,  distended  by  the  enlarging  uterus, 
presents  a  series  of  subepidermic  cracks,  forming  small  plaques  of 
cicatricial  appearance.  These  are  the  linene  albicantes  of  preg- 
nancy.     These  vibices   particularly  occur    in    the   subumbilical 


Modifications  oj  tht  Maternal  Organism. 


79 


region  and  parallel  to  the  fold  of  the  groin.  They  may  also  invade 
the  whole  extent  of  the  al  domen,  i  om<  tin  es  even  the  buttocks  and 
upper  part  of  the  thighs.  By  anomaly,  they  are  exclusively  situated 
in  one  of  these  two  regions.  They  are  rosy  or  bluish  when  recent; 
in  multipara  those  dating  from  a  previous  pregnancy  have  ;i  pearly 
reflex.  They  diminish  in  extent  after  pregnancy,  but  never  dis- 
appear entirely.  In  five  cases  out  of  one  hundred  they  are  wanting. 
These  subcutaneous  ruptures  are  not  exclusively  observed  during 
pregnancy;  they  may  le  produced  by  any  cause  of  abdominal 
detention. 


Fig.  91. — Nipple.     True  and  secondary  areolae.     Tubercles  of  Montgomery. 

6.  Breasts. — We  will  only  touch  here  upon  the  question  of  the 
superficial  changes  of  the  nipple,  the  areola,  and  of  the  contiguous 
integument.  The  nipple  increases  in  size,  becoming  erectile  and 
sensitive,  even  hypera?sthetic  and  painful.  Around  the  nipple  there 
are  two  zones  of  unequal  coloration,  the  most  eccentric  being  the 
least  deeply  colored.  The  first  is  the  true  areola,  existing  before 
pregnancy  and  becoming  more  pigmented  under  its  influence.  The 
hypertrophy  of  Mongomery's  tubercles  and  the  pigmentation  are 
the  two  principal  characters  of  the  areola  during  gestation.  The 
other,  the  secondary  areola,  is  a  pigmentation  of  gravid  origin, 
and  forms  a  circle  surrounding  the  first.  The  subcutaneous  venous 
plexus  becomes  very  apparent.  By  compressing  the  nipple  toward 
the  end  of  pregnancy  some  drops  of  colostrum  often  exude.  The 
colostrum  sometimes  flows  spontaneously. 


II.  Kei-vous  system. — A.  Central. — The  sensitiveness  of  the  preg- 
nant woman  is  usually  exaggerated.  The  intelligence  i-  also 
affected,  so  that  a  naturally  vivacious  woman  becomes  dull  when 
pregnant.  Exceptionally,  a  contrary  modification  has  been  noted. 
Various  perversions  in  the  form  of  morbid  desires  are  to  be  noted. 
Alterations  of  the  will  are  also  often  present  and  border  on  insanity 
in  some  cases. 


80  Modifications  of  the  Maternal  Organism. 

B.  Peripheral. — Pregnancy  predisposes  to  diverse  neuralgias,  and 
in  particular  to  odontalgia,  especially  in  women  whose  dental 
system  presents  a  previous  physiological  inferiority. 

III.  Respiratory  system. — The  development  of  the  uterus  causes 
an  increase  in  the  transverse  diameter  of  the  thorax,  and  on  the 
contrary  a  diminution  of  the  antero-posterior  and  of  the  vertical. 
The  general  capacity  of  the  thorax  is  diminished,  producing  a 
certain  obstruction  to  respiration,  that  is  increased  by  the  globular 
poverty  of  the  blood,  another  effect  of  pregnancy  that  we  shall  soon 
explain.  This  double  cause  exposes  the  pregnant  woman  to  breath- 
lessness. 

IY.  Circulatory  system. — Blood. — There  are  three  principal  modi- 
fications of  the  blood,  namely,  serous  plethora,  globular  anaemia 
(except  as  to  the  leucocytes),  and  diminution  of  the  solid  principles 
(except  fibrin).  The  quantity  of  water  composing  the  blood  is 
notably  increased,  so  that  the  total  mass  of  the  sanguineous  liquid 
is  greater  during  pregnancy.  There  is  then  a  plethora,  but  a 
serous  plethora  or  hydremia.  From  the  exaggeration  of  the  vas- 
cular tension  there  arises  in  the  capillaries  a  quantity  of  serum, 
causing  a  generalized  swelling  of  the  tissues.  This  swelling  should 
not  be  confounded  with  a  certain  degree  of  adipose  tissue  which  is 
a  frequent  result  of  pregnancy  as  we  shall  see  later. 

Besides  the  general  infiltration  of  the  tissues  the  augmentation 
of  the  total  amount  of  blood  has  two  other  effects :  predisposition 
to  haemorrhages  and  obstruction  of  the  functions  of  certain  organs, 
in  particular,  of  the  heart  (hypertrophy,  dilatation)  and  of  the 
kidney  (congestion,  nephritis,  albuminuria).  The  greater  vascular 
tension  produces  more  energetic  pulsation  on  the  part  of  the 
arteries  and  a  tendency  to  dilatation  on  the  part  of  the  veins, 
frequently  terminating  in  the  production  of  varices. 

V.  Urinary  system. — In  the  kidney  we  find  congestion  and  ob- 
struction due  to  the  general  modifications  of  the  circulation  and  to 
the  compression  exercised  by  the  voluminous  uterus.  From  this 
arises  a  predisposition  to  nephritis  and  disturbances  of  secretion, 
which  will  be  studied  with  the  urine. 

Compression  of  the  ureter  is  possible,  especially  when  the  en- 
gagement is  deep,  leading  to  arrest  of  the  flow  of  urine  and  the 
production  of  eclampsia. 

In  its  development  the  uterus  obstructs  the  bladder  more  or  less 
by  its  expansion,  and  causes  changes  in  the  form  and  in  the  situ- 
ation of  the  urinary  reservoir.  During  the  first  three  months  of 
pr<  ^nancy  the  conditions  are  not  notably  changed.  During  the 
3<  eond   three  months,  the  bladder  is  considerably  relieved  from 


Modifications  of  the  Maternal  Organism.  81 

pressure  by  the  ascent  of  the  uterus.  During  the  third  three 
months,  and  also  during  labor  following  the  degree  of  the  fceto- 
uterine  engagement,  the  bladder  takes  different  forms  (Figs.  92, 
93,  94).     The  urethra  follows,  in  part,  the  changes  of  the  bladder. 


Fig  Q2 — B'ndder  in  the  form  of  a  crescent.     Ve,  bladder;   U,  uterus  ; 
R,  rectum  :  V  a,  vagina. 

The  urine  undergoes  three  principal  modifications,  an  augmen- 
tation in  the  quantity  of  water,  diminution  of  the  solid  elements 
(except  the  chlorides),  and  appearance  of  new  elements  (kiestine, 
albumin,  glycose).  The  augmentation  of  the  liquid  portion  is  only 
relative,  for  the  total  quantity  of  urine  is  nearly  the  same  during 
the  pregnant  state  as  in  the  normal  condition.  The  diminution  of  the 
solid  elements  comprises  the  phosphates,  sulphates,  urea,  uric  acid, 
creatine  and  creatinine.     The  chlorides  alone  are  increased.     Under 

m 

the  term  kiestine  has  been  designated  a  special  substance  which 
appears  on  the  surface  of  the  urine  of  pregnant  women.  The  presence 
of  albumen  is  relatively  rare  ;  I  shall  return  to  this  subject  under 
albuminuria.  Apropos  of  glycosuria,  authorities  are  not  in  accord. 
I  reserve  this  subject  for  the  chapter  on  diabetes. 

VT.  Cutaneous  and  osseous  systems. — Besides  the  different  situa- 
tions already  noted,  gravid  pigmentation  may  occur  in  various  other 
parts,  notably  on  the  face.     The  nutrition  of  the  nails  may  be 


82  Modifications  of  the  Maternal  Organism. 


Fig.  93. — Bladder  in  the  form  of  a  slipper. 


Fig.  94. — Bladder  in  the  form  of  a  horn. 


Modifications  of  the  Maternal  Organism.  33 

disturbed,  causing  a  diminution  in  their  thickness.  The  skeleton 
undergoes  modifications  in  its  general  attitude  and  in  its  nutrition. 
In  consequence  of  the  development  of  the  abdomen,  the  woman  to 
maintain  her  equilibrium  is  obliged  to  throw  the  upper  part  of  the 
hotly  backward.  The  puerperal  Btate  also  seems  to  excite  oss< 
development,  as  under  its  influence  there  has  been  noted  on  the 
internal  surface  of  the  cranium,  and  more  rarely  on  the  internal 
Burface  of  the  pelvis,  the  production  of  osteophytes  in  the  form  of 
plaques  which  arise  with  pregnancy  and  disappear  with  it. 

VII.  Digestive  system  and  appendages. — The  liver  undergoes  an 
augmentation  in  volume  and  a  fatty  degeneration  especially  marked 
in  the  centre  of  the  hepatic  lobule.  With  regard  to  the  digestive 
-y-tem,  it  is  subjected  to  very  important  modifications  which  react 
in  a  marked  manner  on  the  nutrition.  Gestation  is  capable  of 
disturbing  more  or  less  deeply  each  one  of  the  four  acts  of  nutrition. 

1.  Absorption.  —  Sometimes  the  appetite  is  excited  under  the 
influence  of  pregnancy,  digestion  is  more  easily  accomplished  and 
absorption  seems  thus  favored.  But  usually  an  opposite  modifi- 
cation is  seen,  so  that  a  retardation  of  absorption  can  be  consideied 
the  rule  during  gestation.  Other  causes  contribute  to  the  retar- 
dation of  absorption,  such  as  vomiting  and  diarrhoea. 

•2.  Assimilation  is  generally  lessened  under  the  influence  of 
pregnancy,  and  this  exercises  a  most  unfavorable  action  on  scrof- 
ulosis  and  anaemia.  Scrofula  already  exercises  an  unfavorable 
action  on  nutrition  and  pregnancy;  by  exaggerating  this  nutritive 
di-turbance  pregnancy  hastens  the  evolution  of  tuberculosis.  Aside 
from  scrofulosis,  the  anaemia  resulting  from  gestation  sometimes 
becomes  so  marked  that  it  constitutes  a  grave  disease. 

3.  Disassimilation. — If  this  process  is  complete,  only  three  waste 
products  result,  that  is,  urea,  carbonic  acid  and  water.  But  if 
disassimilation  is  incomplete,  different  products  arise  among  which 
I  shall  note  uric  acid,  lactic  acid,  sugar  and  fat.  The  excess  of 
these  products  in  the  blood,  or  in  the  eliminative  organ  (urinary  or 
biliary  passages),  produces  the  different  diseases  indicated  by  the 
following  table : 

Excess  of  lactic  acid  causes  i  f>h™m^s™> 
I  Osteomalacia. 

r-  c  ■  j  f  Gout, 

Lxcess  of  uric  acid  causes     <  T.  .    '  , 

(.  L  nnary  gravel. 


Excess  of  fat  causes 


f  Obesity. 

\  Biliary  lithiasis. 


Excess  of  sugar  causes     -      1  /^,^C3emi?"    _.  , 

I  Glycosuria,  Diabetes. 

Now,  pregnancy  favors  the  development  of  the  different  diseases 
by  retarding  the  disassimUative  stage  of  nutrition. 

4.  Elimination  occurs  through  the  skin,  the  intestine  (comprising 


84  The  Parturient  Canal. 

its  tributary  glands,  the  liver  in  particular),  the  lungs  and  the 
kidneys.  We  have  seen  that  the  analysis  of  the  gravid  urine  shows 
a  diminution  of  the  solid  elements  (except  the  chlorides).  Benal 
elimination  is  lessened  then,  and  it  is  probable  that  the  same  is 
true  with  regard  to  the  pulmonary,  cutaneous  and  intestinal  elimi- 
nation. When  this  retardation  of  elimination  becomes  too  marked, 
it  terminates  in  a  pathological  state,  eclampsia. 


CHAPTER  IV. 


THE   PARTURIENT   CANAL. 

The  parturient  canal  is  a  narrowed  and  irregular  region  through 
which  the  foetus  must  pass  at  the  moment  of  delivery.  This  canal 
is  constituted  by  an  osseous  region,  which  forms  its  framework, 
the  bony  pelvis,  and  is  completed  by  the  soft  parts  below,  which  as 
a  whole  may  be  called  the  soft  pelvis  or  perineum. 

I.  Bony  pelvis. — The  pelvis  is  formed  by  the  two  iliac  bones, 
adherent  at  the  symphysis  pubis,  and  reunited  posteriorly  by  the 
intermediate  sacrum  with  its  inferior  appendix,  the  coccyx.  This 
sketch  allows  us  to  note  four  articulations,  the  symphysis  pubis  in 
front,  the  two  sacro-iliac  symphyses,  one  on  each  side  of  the  sacrum, 
and  finally  the  sacro-coccygeal  articulation.  The  pelvic  ring,  in- 
terposed between  the  vertebral  column  and  the  lower  members, 
plays  an  important  physiological  part.  In  its  description  I  shall 
confine  myself  exclusively  to  the  obstetrical  side  of  the  question. 

External  conformation. — The  exterior  of  the  pelvis  interests  the 
obstetrician  but  little ;  however,  as  in  certain  vices  of  conforma- 
tion the  measurement  of  some  external  diameters  furnishes  useful 
knowledge,  I  shall  indicate  four  of  these  : 

1.  The  sacro-pubic,  from  the  spinous  process  of  the  first  sacral 
vertebra  to  the  anterior  and  median  part  of  the  symphysis  pubis, 
twenty  centimetres. 

2.  The  bispinous,  separating  the  two  anterior  superior  iliac 
spines,  twenty-four  centimetres. 

3.  The  bis-iliac,  uniting  the  two  most  distant  points  of  the  iliac 
crests,  twenty-eight  centimetres. 

4.  The  bitrochanteric,  from  the  great  trochanter  of  one  side  to 
that  of  the  other,  thirty-two  centimetres. 


Tht   Parturient  Canal. 


-- 


Internal  conformation. — In  it-  interior  tlie  pelvis  presents  two 
absolutely  distinct  regions,  separated  by  a  retraction  that  consti- 
tutes the  linea-ilio-pectinea  completed  behind  by  the  promontory, 
and  to  which  is  given  the  term  superior  strait.  Above  this  is  found 
the  great  or  false  pelvis ;  below  it  is  the  true  pelvis. 


Fig.  95.— False  pelvis  covered  by  the  soft  parts.  A,  aorta:  A  I  PG,  left  primary 
iliac  artery;  A  I  EG,  left  external  iliac  artery;  M  P,  psoas  muscle;  CM  A,  section 
of  the  muscles  of  the  abdominal  wall;  GT,  great  trochanter;  MI,  iliac  muscle;  M 
CL,  quadratus-lumborum  muscle;  V  C  I,  inferior  vena  cava;  VI  PG,  left  primary 
iliac  vein;  A S V,  sacro- vertebral  nn^'le;  1 1.8,  insertion  of  sacro-sciatic  ligaments; 
MO  E,  external  obturator  muscle;   A  I  P,  inferior  arch  of  the  pubes. 

The  false  pelvis  forms  an  incomplete  funnel,  constituted  by  the 
iliac  wings  laterally,  and  the  spinal  column  behind.  The  ilio-psoas 
muscles,  by  filling  the  iliac  fossa?,  offer  a  support  to  the  gravid 
uterus  when  it  inclines  to  one  side. 

But  the  true  pelvis  is  essentially  the  obstetrical  part  of  the  pelvis. 
It  is  limited  above  by  the  superior  strait,  already  defined,  and 
below  by  the  inferior  strait  (point  of  the  coccyx,  inferior  part  of 
the  saco-sciatic  ligaments,  ischium,  ischio-pubic  rami,  inferior  part 
of  the  pulic  symphysis). 

Between  these  two  straits  is  found  the  pelvic  excavation.  At  the 
inferior  part  of  the  excavation  a  contracted  portion,  the  median 
strait,  divides  it  into  two  unequal  parts :  one,  superior,  the  great 
excavation;  one,  inferior,  the  small  excavation. 

The  median  strait  is  of  considerable  importance  in  obstetrics. 
It  constitutes  the  limit  between  the  bony  pelvis  and  the  muscular 
pelvis;  above  it,  the  foetus  passes  through  a  bony  canal;  below  it, 
through  a  muscular  canal.     Above  it  lies  pelvic  dystocia:  below  it 


86 


The  Parturient  Canal. 


(except  in  obstacles  furnished  by  the  ischium  and  coccyx)  we  have 
perinseo- vulvar  dystocia. 

For  complete  recognition  of  the  true  pelvis  it  is  necessary  to  de- 
scribe successively : 

a.  The  superior  strait. 

(•.  The  great  excavation. 

c.  The  median  strait. 

d.  The  lesser  excavation. 

e.  The  inferior  strait. 

a.  Superior  strait. — Formed  by  the  promontory,  projecting  part  of 
the  wings  of  the  sacrum,  innominate  line  of  the  ilium,  ilio-pectineal 
eminence,  pectineal  surface,  pubic  spine,  superior  part  of  the  pubis 
and  of  the  symphysis  pubis. 

Diameters. — 

1.  Antero-posterior  or  sacro-pubic,  eleven  centimetres. 

2.  Ttco  oblique;  the  left  from  the  right  sacro-iliac  symphysis  to 
the  left  ilio-pectineal  eminence ;  the  right  from  the  left  sacro-iliac 
symphysis  to  the  right  ilio-pectineal  eminence.  These  two  diame- 
ters are  equal  and  measure  twelve  centimetres. 

3.  A  transverse,  uniting  transversely  the  two  most  distant  points 
of  the  innominate  line,  fourteen  centimetres. 

b.  The  great  excavation,  or  the  Excavation,  properly  so-called. — 
Formed  by  the  sacral  concavity,  the  great  sciatic  notch,  the  os- 
seous surface  extending  from  the  ischium  to  the  iliac  wing,  the 
obturator  foramen,  the  posterior  surface  of  the  pubis  and  of  the 
symphysis  pubis. 


Fig.  96. — Pelvis :  diameters  of  the  superior  strait. 

Dianu  tere. — 

1.  An  antero-posterior,  from  the  median  part  of  the  third  sacral 
vertebra  to  the  middle  of  the  posterior  inter-line  of  the  symphysis 
pubis,  twelve  centimetres. 


The  Parturient  ( 'anal. 


< 


2.  Two  oblique:  the  left,  better  called  the  cacal,  from  the  middle 
of  the  right  sciatic  notch  to  the  middle  of  the  left  obturator  foramen  ; 
the  right,  better  the  rectal,  follows  an  opposite  direction;  both 
measure  twelve  centimetres.  However,  the  two  extremities  of  tl 
diameters,  corresponding  to  soft  parts,  are  easily  extended  to 
thirteen  centimetres,  and  even  more. 

3.  A  transverse:  from  a  point  corresponding  to  the  base  of  one 
cotyloid  cavity  to  that  of  the  other,  twelve  centimetres. 

c.  The  median  strait. — Formed  by  :  the  inferior  part  of  the  sacrum, 
the  inferior  border  of  the  lesser  sacro-sciatic  ligament,  the  sciatic 
Bpine,  a  line  from  this  spine  to  the  inferior  part  of  the  pubic 
symphysis. 


FlG.  97. — Pelvis:  diameters  of  the  excavation. 

Diameters. — 

1.  An  antero-posterior,  from  the  inferior  and  median  part  of  the 
sacrum  to  the  inferior  part  of  the  symphysis  pubis,  twelve  centi- 
metres. 

•1.  Two  oblique:  a  caeal,  from  the  middle  of  the  right  lesser  sacro- 
sciatic  ligament  to  the  middle  of  the  ischio-pubic  border  and  of  the 
left  obdurator  foramen ;  a  rectal,  identical  in  the  opposite  direction. 
Both  measure  eleven  centimetres. 

3.  A  transverse:  extending  from  the  sciatic  spine  of  one  side  to 
that  of  the  opposite,  ten  centimetres. 


'/.  e.  Lesser  excavation  and  inferior  strait. — I  unite  these  two  regions 
in  one  description.  Their  importance  is  only  secondary  in  relation 
to  the  preceding.  The  inferior  strait,  according  to  classical  de- 
scriptions, is  constituted  by  the  point  of  the  coccyx,  the  inferior 
border  of  the  great  sacro-sciatic  ligament,  the  ischium,  the  ischio- 
pubic  rami  and  the  inferior  part  of  the  symphysis  pubis.  Xow  I 
shall  remark : 

1.  That  the  great  sacro-sciatic  ligament  does  not  extend  to  the 
point  of  the  coccyx,  but  from  the  base  of  this  bone  to  the  ischium, 
so  that  the  inferior  strait  is  without  limit  in  this  region. 


88 


The  Parturient  Canal. 


2.  That  the  coccyx,  from  its  mobility,  plays  the  role  of  a  soft 
part,  its  point  consequently  cannot  serve  to  limit  a  fixed  osseous 
strait,  this  would  only  be  possible  in  ankylosis  of  the  articulation  of 
this  bone  with  the  sacrum,  a  pathological  condition  and  relatively 
rare. 


Fig.  98. — Pelvis:  diameters  of  the  median  strait. 

3.  That  the  line  uniting  the  ischiatic  bones  is  found  much  above 
that  going  from  the  point  of  the  coccyx  to  the  inferior  part  of  the 
symphysis  pubis,  and  that  for  this  reason  these  parts  cannot  con- 
tribute to  the  formation  of  a  single  plane. 

4.  That  the  cocey-perimeal  muscle  by  its  insertion  rises  above 
the  inferior  strait  and  removes  almost  all  its  importance,  in  an 
obstetrical  point  of  view. 


These  different  reasons  argue  for  the  acceptance  of  the  median 
strait  as  the  real  limit  of  the  excavation  interiorly.  It  conforms 
better  to  the  reality  to  consider  the  inferior  strait,  not  as  a  true 
strait,  but  as  a  simple  osseous  tripod,  formed  by  the  two  ischiatic 
bones  and  the  coccyx,  these  three  projections  being  separated  by 
three  deep  notches,  the  pubic  in  front,  the  sacro-sciatic  laterally. 
It  is  comprehended  then  that  a  displacement  (of  the  ischiatic  bones) 
and  a  fixation  (coccyx)  may  become  a  cause  of  dystocia.  Thus  it 
is  well  to  know  that  in  the  normal  state  the  distance  which  separates 
the  two  ischiatic  tuberosities  is  eleven  centimetres,  and  that  which 
usually  extends  from  the  point  of  the  coccyx  to  the  inferior  part  of 
the  symphysis  pubis  is  nine  centimetres,  but  is  very  extensible. 

Placing  in  relation  the  dimensions  of  corresponding  diameters  we 
have : 


Diameters. 

Transverse. 

Oblique. 

Antero-posterior 

Superior  strait 

'3 

12 

11 

Excavation 

12 

12 

12 

Median  strait 

10 

II 

12 

The   I'uriiirii  nt   <  'mini .  39 

It  will  be  seen  then,  by  recalling  thai  in  the  excavation  the  oblique 
diameters  present  a  notable  extensibility,  that  the  great  dimensions 
of  the  pelvis  are  : 

Transverse  at  the  superior  strait. 

Oblique  in  the  excavation. 

Antero-po8terior  at  the  median  strait. 

We  can  now,  from  these  figures,  foresee  the  situation  of  the  fetal 
head  in  its  descent  through  the  osseous  canal.  The  head  will  place 
its  greatest  dimension,  that  is,  the  occipito-mental  diameter,  so  that 
its  position  will  lie : 

Transverse  at  the  superior  strait. 

Oblique  in  the  excavation. 

Direct  at  the  median  strait. 

II.  Soft  pelvis. — Perinmim. — The  pelvic  skeleton  constitutes  one 
of  the  most  important  muscular  centers.  Of  these  muscles  some 
descend  from  the  thorax  to  an  insertion  on  its  upper  border;  others 
are  inserted  on  its  external  surface ;  finally,  the  last,  which  interest 
us  more  especially,  are  fixed  to  the  internal  surface  of  the  pelvis, 
lining  its  walls  and  closing  its  inferior  opening.  Let  us  follow  the 
latter  muscles  from  the  superior  toward  the  inferior  part  of  the 
pelvis.  Above  the  superior  strait,  tilling  the  iliac  fossae,  are  the 
psoas  muscles,  which  we  have  already  had  in  question.  Below  the 
superior  strait,  after  having  raised  the  pelvic  aponeurosis,  which 
forms  a  fibrous  mass  solidly  closing  the  pelvis  below,  is  found  a 
most  important  muscular  plane,  lining  the  pelvis  and  also  closing 
it  below.  The  muscles  thus  uncovered  (Fig.  99)  are  posteriorly 
the  pyramidals ;  laterally  and  in  front,  the  internal  obturators,  and 
finally,  in  the  center  of  this  large  space  is  found  the  coccy-perinseal 
elevator,  which  it  would  be  more  simple  to  call  the  levator  perinaei. 
The  internal  obturator  passes,  from  its  insertion  around  the 
obturator  foramen,  between  the  sciatic  spine  and  the  ischium  to 
become  fixed  in  the  great  trochanter.  The  pyramidahs,  from  its 
origin  on  the  anterior  and  lateral  surfaces  of  the  sacrum,  passes 
out  through  the  great  sacro-sciatic  notch  to  become  fixed  on  the 
great  trochanter  also.  The  coccy-perinaeal  elevator,  or  simply  the 
perineal,  forms  a  trough,  a  hammock,  transversely  in  the  pelvis, 
attached  laterally  to  the  sciatic  spine,  to  the  pubis  and  to  a  fibrinous 
intersection  which  unites  these  two  points.  Posteriorly  it  is 
attached  to  the  coccyx  and  to  the  inferior  part  of  the  sacrum 
while  it  is  free  in  front  and  is  limited  by  the  posterior  vaginal  wall. 
It  is  on  this  hammock  that  the  organs  of  the  pelvis  rest.  This 
hammock  supports  the  fcetal  head,  which  depresses  it  in  its  passage 
to  the  vulvar  orifice. 

The  levator  possesses  several  fasciculi  which  by  their  union  con- 
stitute  one   muscle.     The   first  fasciculus,   the    ischio-coccygeal, 


90 


The  Parturient  Canal. 


extends  from  the  sciatic  spine  to  the  lateral  parts  of  the  coccyx. 
The  second  fasciculus,  the  coccygeal,  arising  from  the  fibrous  inter- 
section between  the  sciatic  spine  and  the  pubis,  has  its  fibres  con- 
verging toward  the  point  of  the  coccyx.  The  third  fasciculus,  the 
ano-vulvar,  particularly  resisting,  arises  in  front  at  the'  inferior 
and  posterior  part  of  the  pubis  and  forms  a  fan  interlacing  with 
the  fibres  of  the  opposite  side,  between  the  coccyx  and  anus  for  one 
part  and  the  rectum  and  vagina  for  the  other  part;  some  fibres 
terminating  on  the  lateral  portions  of  the  rectum  and  vagina. 


Rectum  (anus.) 


Ischium     coccy- 
geal fasciculus. 

Pyramidal. 

Sacrum. 


FlG.  99  — Pelvic  diaphragm.     Internal  obturators.     Pyramidial  muscles. 
Coccy-perinseal  elevator. 

Examined  as  a  whole,  the  fibres  of  this  levator  may  be  divided  into 
three  fans  on  each  side,  disposed  in  opposed  directions :  a  sciatic 
fan,  with  the  point  at  the  sciatic  spine  and  the  base  at  the  lateral 
border  of  the  coccyx;  a  coccygeal  fan,  with  the  point  at  the 
extremity  of  the  coccyx  and  the  base  at  the  fibrous  intersection  join- 
ing the  sciatic  spine  and  the  pubis,  and  a  pubic  fan,  with  the  point 
at  the  pubis  and  the  base  on  the  coccy-vulvar  median  line. 

The  coccyx  is  thus  included  in  the  muscle  and  forms  a  de- 
pendent portion.  This  bone,  being  mobile  at  its  articulation  with  the 
sacrum,  follows  the  fibres  in  their  different  movements.  Thus,  when 
the  foetal  part  distends  the  muscular  mass  the  coccyx  is  pushed 
backward  with  the  muscular  fibres.  This  bone,  a  hard  part  in  the 
static  state,  should  be  considered  as  a  soft  part  in  the  dynamic 
state.  This  pushing  back  of  the  coccyx  makes  a  portion  of  the 
amplification  of  the  perinaeum.  It  marks  the  beginning  of  the  period 
of  expulsion.  It  is  the  first  obstacle  met  by  the  foetal  part  at  the 
beginning  of  this  period.  But  this  obstacle  will  usually  be  easily 
overcome,  unless  there  is  ankylosis  of  the  sacrococcygeal  articu- 
lation.    There  then  exists  a  veritable  cause  of  dystocia. 

The  anterior  portion  of  the  levator  perinsei,  the  part  in  contact 
with  the  posterior  vaginal  wall,  may  also  become  a  cause  of  dystocia. 


Tin   Parturient  ( 'anal. 


9] 


Budin,  who  has  particularly  studied  this  cause  of  dystocia,  has 
clearly  established  the  fact  thai  this  anterior  portion  oi  the  Levator 

may  be  an  obstacle  to  exploration,  to  coitus,  ami  to  delivery. 


£  a 


Bulbusvestibuli 


Ischio-cavern- 
ous  muscle. 


Oe^ptransverse 


External 

sphincter  of  the 

anus. 


Fig.  ioo.  — Schema  representing  the  superficial  muscles  of  the  perinreum. 

Thus  constituted  the  levator  perinsei  is  to  the  abdominal  cavity 
(at  the  inferior  pelvic  opening)  what  the  diaphragm  is  to  the  inferior 
thoracic  opening.  The  perineal  elevator  is  covered  and  completed 
superficially  by  a  series  of  muscles,  which  must  be  described  in 
brief.     Of  these  muscles,  one  surrounds  the  termination  of  the 


92 


The  Parturient  Canal. 


intestine ;  this  is  the  external  sphincter  of  the  anus.  The  others 
are  disposed  around  the  vulva.     They  are: 

1.  The  constrictor  of  the  vulva,  a  muscular  ring  enveloping  the 
vaginal  bulbs.     Its  contraction  produces  inferior  vaginismus. 

•2.  The  superficial  transverse  muscle,  a  muscular  band  thrown 
from  one  ischium  to  the  other. 

3.  The  deep  transverse  muscle,  a  simple  muscular  vestige  pass- 
ing from  the  ischio-pubic  ramus  to  the  corresponding  bulb  of  the 
vagina. 

4.  The  ischio-cavernous  muscle,  enveloping,  along  the  ischio- 
pelvic  rami,  the  root  of  the  cavernous  bodies. 

5.  Wilson's  muscle,  composed  of  some  muscular  fibres  passing 
from  the  internal  surface  of  the  pubis  to  the  urethra. 


Fig.  ioi  . — Antero-posterior  section  of  the  muscles  and  aponeuroses  of  the  perinaeum 
(Schema).  MW,  Wilson's  muscles;  T  P,  deep  transverse;  CV,  vulvar  constrictor; 
T  S,  superficial  transverse;  R  C  P,  coccy-peritonseal  elevator;  S  A,  anal  sphincter 
(external  sphincter]. 

Thus  we  have  two  muscular  planes  constituting  the  perinseum : 
A  deep  plane,  consisting  of  the  perineal  elevator,  which  is,  conse- 
quently, the  pelvic  diaphragm ;  a  superficial  plane,  represented  by 
the  muscles  subjacent  to  the  skin.  Through  these  tissues  pass 
vessels  and  nerves.  Thus  comprised,  the  perinaBum  gives  passage 
to  three  important  organs,  the  rectum  behind,  the  urethra  in  front 
and  the  vagina  in  the  middle.  To  terminate  the  study  of  the  geni- 
tal canal  there  remain  for  description  the  vagina  and  its  appendage, 
the  vulva. 


The  Partwrient  Canal. 


98 


The  vapina  is  a  canal  of  cylindrical  form,  inserted  byita  superior 
emity  on  the  cervix,  forming  the  culs-de-sac,  and  continai 
its  inferior  extremity  with  the  \  nlva  at  the  level  of  the  hymen.  Its 
length  is  ten  centimetres,  measured  to  the  posterior  cul-de-sac.  Its 
externa]  Burface  is  in  relation  to  the  surrounding  viscera,  the  rectum 
behind,  the  bladder  in  front;  and  inferiorly,  muscular  relations 
with  the  pelvic  floor.  Thus  the  vagina  forma  a  largo  and  spacious 
cavity  in  the  vicinity  of  the  uterus  and  becomes  narrowed  at  the 
vulva. 


Praputium  clitoridis. 
Clitoris. 
Labia  majora. 


Labia  minora.  . 

Urethral  tubercleand ^ 

urethra. 


Vaginal  orifice. 

Hymen. 

Fossa  naviculars. 

Perinaeum. 
Anus. 


/         Mons  veneris. 
Labia  majora. 


Orifice  of  Bartholin's 
Iw    S5  ~ "iSfc     "  gland. 


Fourchette. 


Fig.  102. — Virginal  vulva. 

In  exploring  the  internal  surface  of  the  vagina,  by  separating  the 
two  walls,  it  is  found  to  have  a  rosy  tint,  in  the  normal  state ;  a 
violaceous  during  pregnancy.  On  both  the  anterior  and  posterior 
walls  exists  a  longitudinal  projection  called  the  vaginal  column 
(anterior  and  posterior). 

The  vagina  is  composed  of  three  coats :  an  external,  composed  of 
connective  tissue  and  elastic  fibres ;  a  middle,  of  non-striated  mus- 
cular tissue,  of  which  the  eccentric  fibres  are  longitudinal,  and  the 
concentric  circular,  an  internal,  mucous,  totally  deprived  of  glands 
but  rich  in  papillae  that  are  covered  by  stratified  pavement  epithe- 
lium. 


94  The  Parturient  Canal. 

The  vulva  is  composed  of  three  successive  and  concentric  planes : 
First  plane. — Mons  veneris,  labia  majora,  perinceum. — The  labia 
majora  form  two  vertical  folds,  blending  above  with  the  mons 
veneris,  and  becoming  effaced  below  on  the  perinseum.  In  the 
center  of  the  oval  thus  formed  are  found  the  other  vulvar  parts. 
The  external  surface  of  the  labia  is  cutaneous  and  covered  with 
hair ;  the  internal  surface  is  smooth,  normally  moist  and  the  two 
labia  are  often  in  contact.  This  contact  is  destroyed  by  the 
separation  of  the  thighs. 

Second  plane. — Pr&putium  clitoridis,  nymphce,  fourchette. — The 
nymphse  are  two  folds  analogous  with  and  parallel  to  the  labia 
majora,  but  much  more  thin.  Above  they  separate  to  enclose  the 
clitoris.  Of  the  two  folds  formed  by  this  separation,  one  forms  the 
prepuce  of  the  clitoris,  the  other  forms  the  frsenum.  Below,  the 
nymphfe  diminish,  and  are  united  by  a  small  fold  called  the 
fourchette. 

Vagina. 

■**-. ^____^---r  Post-navicular  commissure. 

V  Navicular  fossa. 

^- ^  Anterior  navicular  commissure 

\  _>»^^ ••      Ano-vulvar  perinaeum. 


Fig.  103. — Perineo-vulvar  profile. 

Third  plane. — Vestibule,  meatus  urinarius  and  its  tubercle,  vagina 
and  hymen. — In  the  space  circumscribed  by  the  base  of  the  nymphse 
is  found  an  elliptical  surface  that  can  be  considered  as  divided  into 
two  equal  parts  by  a  transverse  line.  Above  this  line  is  the 
vestibule,  below  it  is  the  vaginal  orifice.  The  vestibule  presents 
the  urethral  tubercle  with  the  meatus  urinarius.  The  vaginal 
orifice,  below  this,  is  more  or  less  protected  by  the  hymen,  or  the 
carunculse  which  represent  its  remains.  The  fossa  navicularis  is  a 
small  depression  situated  between  the  fourchette  and  the  hymen  or 
its  debris.  Laterally  the  fossa  navicularis  is  lost  on  the  sides  of 
the  vulva ;  anteriorly  and  posteriorly  it  is  limited  by  the  anterior 
and  posterior  navicular  commissures  (Fig.  103).  The  vulva  is 
separated  from  the  vagina  by  the  hymen.  The  intact  hymen  may 
pic -cut  various  conformations  (Figs.  104  to  111).  At  the  first  coitus 
the  hymen  is  usually  ruptured,  leaving  the  hymeneal  carunculse 
(Fig.  112).  After  accouchement,  these  ruptures  become  deep  and 
by  isolated  cicatrization  form  the  carunculse  myrtiformes  (Fig. 
113).  In  rare  cases  the  hymen  may  remain  intact  after  coitus,  and 
even  after  parturition.  In  exceptional  cases,  pregnancy  has  been 
noted  with  an  imperforate  hymen. 


Tin   Parturient  Canal. 


'.'.", 


Resume  of  the  parturient  canal. — Planes  and  axes. — The  parturient 
canal,  consisting,  as  has  been  seen,  of  an  osseous  passage  and  of 
a  Boft  passage,  is  somewhat  modified  in  it-  08S<  ous  portion  by  the 
presence  of  soft  parts  which  retract  the  different  diameters  of  the 
pelvis,  but  which,  nevertheless,  do  not  alter  the  general  form. 


Fig.  104. — Crescent  hymen. 


Fig.  105. —  Hymen  with 
a  small  diaphragm. 


F;g.  106. — Hymen  with 
a  large  diaphragm. 


Fig.  107. — Cleft  hymen.  Fig.  10S. — Fringed  hymen. 


FlG.  109. — Hymen  with 
double  slit. 


FlG.  1 10. — Hymen  with  a 
double  orifice. 


Fig.  in. — Cubiform  hvmen. 


Fig.  112. — Hymeneal  caruncul.-e. 


Fl  3.  1 13. — Caruncula:  myrtiformes. 


The  plane  of  the  superior  strait,  with  the  woman  in  the  erect 
position,  forms  an  angle  of  sixty  degrees  with  the  horizontal.  The 
plane  of  the  inferior  strait  is  more  closely  approached  to  the  hori- 
zontal, but  without  coinciding  with  it.  This  difference  of  inclination 
is  due  to  the  unequal  bight  of  the  pelvic  walls,  winch,  in  front 


96 


The  Parturient  Canal. 


(pubis)  measure  five  centimeters,  and  behind  (sacrum)  ten  cent 
metres. 

The  axis  of  the  superior  strait,  that  is  the  perpendicular  to  the 
center  of  its  plane,  passes  from  the  umbilicus  toward  the  middle 
of  the  coccyx.  That  of  the  median  strait  extends  from  a  point 
situated  a  little  in  advance  of  the  promontory  toward  the  anus. 
The  direction  of  the  axis  of  the  pseudo  inferior  strait  is  quite 
variable  on  account  of  the  mobility  of  the  coccyx.  The  direction  of 
these  axes  is  very  important  in  practice,  for  they  indicate  the 
direction  in  which  the  tractions  on  the  foetus  should  be  made. 


Fig.  114.. — Fish-hook  curve  of  the  parturient  canal. 

The  general  axis  of  the  parturient  canal,  from  the  superior  strait 
to  the  vulva,  is  not  an  arc  of  a  circle,  as  described  by  Carus,  nor  an 
angle,  as  maintained  by  Fabbri,  but  rather  a  fish-hook,  as  Tarnier 
has  indicated,  that  is,  rectilinear  in  the  osseous  portion  and  curved 
in  the  arc  of  a  circle  in  the  soft  parts  (Fig.  114).  This  curve  is  of 
the  greatest  interest  to  the  obstetrician,  as  will  be  seen  later. 


Presentations  and  Positions.  07 


CHAPTER  V. 


PRESENTATIONS   AND   POSITIONS. 

Presentations. — The  foetus,  enclosed  in  the  uterine  cavity,  is 
separated  from  the  exterior  by  the  parturient  canal,  which  it  must 
traverse  at  the  moment  of  labor.  For  this  exit,  it  may  he  placed 
in  different  ways,  presenting  to  the  genital  opening  so  many  different 
regions  of  the  body.  The  symptoms  furnished  by  foetal  exploration 
and  the  mechanism  of  delivery,  will  necessarily  vary  according  to 
these  different  cases.  The  necessity  of  a  classification  of  the  foetal 
presentations  is  thus  imposed  on  obstetricians.  Eolled  up  in  the 
uterine  cavity,  the  child  is  generally  flexed.  This  general  flexion 
is  accomplished  by  a  series  of  partial  flexions.  Thus,  the  head  is 
flexed  on  the  trunk,  the  forearms  on  the  arms,  the  hands  on  the 
forearms,  the  thighs  on  the  trunk,  the  legs  on  the  thighs,  the  feet 
on  the  legs— flexion  everywhere.  In  this  attitude,  which  singularly 
favors  the  reduction  of  the  foetal  mass,  the  child  offers  the  form  of 
an  ovoid,  the  large  extremity  corresponding  to  the  breech  and  the 
small  extremity  to  the  head.  This  is  the  somatic  ovoid.  The  somatic 
ovoid  (Fig.  115)  is  divided,  as  explained  before,  into  the  cephalic 
ovoid  and  the  cormic  ovoid. 


Fig.  115. — Somatic  ovoid  formed  by  the  union  of  the  two  ovoids, 
cephalic  and  cormic. 

The  cephalic  ovoid,  though  smaller  than  the  cormic  ovoid,  is  le-s 
reducible.  Its  great  axis  extends  from  the  chin  to  the  sagittal 
suture,  a  little  in  advance  of  the  lambda.  Considered  in  its  trans- 
verse dimensions,  it  presents  a  series  of  points  serving  as  marks  of 


98 


Presentations  and  Positions. 


other  diameters ;  these  are  the  biparietal,  bifrontal,  bimalar  and 
biasteric. 

The  cormic  ovoid,  more  or  less  deformed  by  the  addition  of  the 
superior  and  the  inferior  members,  presents  its  great  diameter  from 
the  breech  to  the  summit  of  the  thorax.  It  also  offers  transverse 
diameters,  such  as  the  bisacromial  and  bitrochanteric.  These  two 
ovoids  are  united  by  the  neck. 


Fig.  i  i 6. — Vertex 
presentation. 


Fig  117. — Face 
presentation 


Fig.  118. — Brow 
presentation. 


Fig.  119. — Breech  presentation.       Fig.  120. — Thorax  presentation. 

The  foetus  presents  at  the  genital  canal,  usually  by  the  cephalic 


Presentations  and  Positions.  99 

ovoid,  sometimes  by  the  cormic  ovoid.  But  every  ovum,  to  pass 
through  the  parturient  canal,  may  open  it  by  the  large  or  by  the 
1  extremity,  or,  again,  transversely.  Theoretically,  there  are, 
then,  three  presentations  for  every  ovoid  :  large  end,  small  end,  and 
transversely.  The  Bame  is  true  with  regard  to  each  of  the  fcetal 
ovoids. 


Fig.  121. — Abdomen  (lumbar)  presentation. 

The  cephalic  ovoid  may,  in  fact,  present : 

1.  Sometimes  by  its  large  extremity  (vertex)  (Fig.  116). 

2.  Sometimes  by  its  small  extremity  (face)  (Fig.  117). 

3.  Sometimes  transversely  (brow)  (Fig.  118). 

The  cormic  ovoid  also  may  present : 

1.  Sometimes  by  its  large  extremity  (breech)  (Fig.  119). 

2.  Sometimes   by  its   small   extremity  (thorax   or   shoulder) 
(Fig.  120).  _ 

3.  Sometimes  transversely  (loins  or  abdomen)  (Fig.  121). 

We  have  then  six  presentations  : 

Cephalic  ovoid.  Cormic  ovoid. 

1.  Vertex.  I.  Breech. 

2.  Face.  2.  Thorax  (shoulder). 

3.  Brow.  3.  Abdomen  (loins). 

The  vertex  and  the  breech  are  identical ;  they  represent  the  large 
extremity  :  one  the  cephalic  ovoid  ;  the  other  the  cormic  ovoid.  The 
face  and  the  thorax  are  analogous,  they  represent  the  two  small 
extremities.  The  analogy  is  the  same  for  the  brow  and  the  lumbo- 
abdominal  region ;  the  ovoids  are  placed  transversely. 

Of  the  six  presentations,  each  comprise  one  of  the  zones  of  the 
two  fcetal  ovoids  limited  by  the  following  planes  :  For  the  cephalic 
ovoid,  two  planes  perpendicular  to  the  long  axis  of  the  head,  passing, 
one  through  the  root  of  the  nose,  the  other  through  the  posterior 
angle  of  the  bregma.  For  the  cormic  ovoid,  two  planes,  also  per- 
pendicular to  the  long  axis,  and  passing,  one  through  the  summit 
of  the  iliac  crests,  the  other  through  the  point  of  the  zyphoid  ap- 
pendix (Fig.  122'. 


100 


Presentations  and  Positions. 


Relative  frequency  of  these  different  presentations 


Vertex, 
Face,    -     - 
Brow,  -     - 
Breech, 
Thorax, 
Abdomen, 

19  out  of    20  parturitions. 
1       "       250 
1       "      300 
I       "         30 
1       "       125 
1       "     1000           "         (Relatively  too  high) 

The   following  proportions   may  also   be  adopted.     Out  of  one 

thousand  parturitions  there  exist : 

Vertex, 
Face,    -     - 
Brow,  -     - 
Breech 
Thorax,     - 
Abdomen, 

956  deliveries. 
4 
3 

30 
6 
1           " 

(I  recall  again  that  1  to  1000  for  the  abdomen  is  relatively  too 
high.) 


Occipito  -  mental  J    j.j"  p-ace 
portion.  1  m;  Br0^ 


Pelvi-cervical 
portion. 


I.  Breech. 
II.  (Shoulder)  Thorax. 
III.  Back  and  abdomen. 


Fig.  122. — Schema  of  presentable  zones. 

Each  of  these  six  presentations  has  four  varieties.  These  varieties 
are  of  secondary  importance  to  the  cephalic  ovoid,  and  only  indicate 
a  simple  inclination  of  the  foetal  part  which  presents.  A  simple 
enumeration  will  be  sufficient : 


I.    Vertex. — Variety, 


Occipital  (exaggerated  flexion). 

Frontal  (flexion  little  marked). 

Right  parietal  (right  parietal  quite  accessible). 

Left  parietal  (left  parietal  quite  accessible). 


Presentations  and  Positions. 


lul 


II.  Face. — Variety, 


III.  Brow. — Variety, 


(Mental  (extension). 
I  (extension  not  marked). 
Right  malar  (right  malar  quite  accessible). 
Left  malar  (left  malar  quite  accessible). 

(Parietal  (tendency  to  flexion). 
Facial  (tendency  to  extension). 
Right  temporal  (right  temporal  quite  accessible). 
[  Left  temporal  (left  temporal  quite  accesiblej. 


For  the  cormic  ovoid,  on  the  contrary,  these  varieties  are  im- 
portant, for  they  lead  to  practical  consequences  that  will  be  studied 
later. 


FiG.  123. —  Complete  breech. 

I.  Breech. — 

1.  Complete  variety. — The  inferior  limbs  are  flexed  and  close  to  the 
pelvis.    This  is  the  type  for  presentation  of  the  breech  (Fig.  123). 

2.  Incomplete  variety. — Thighs. — The  pelvic  members  are  raised 
up  along  the  anterior  plane  of  the  foetus  (Fig.  124). 

3.  Incomplete  variety. — Knees. — The  thighs  are  extended,  but  the 
legs  flexed  on  the  thighs,  so  that  the  knees  constitute  the  lowest 
foetal  part  (Fig.  125). 

4.  Incomplete  variety. — Feet. — The  inferior  limbs  are  extended, 
and  the  feet  descend  first  (Fig.  126). 


II.  Thorax  — 

1.  Variety  of  the  right  shoulder  (that  is,  the  region  of  the  right 
shoulder  presents.) 

2.  Left  shoulder. 

3.  Back  (thoracic  portion). 

4.  Sternum. 


102 


Presentations  and  Positions. 


Thus  one  of  the  four  surfaces  of  the  thorax  presents  (anterior, 
posterior,  right  or  left  lateral). 


Fig.  124. — Incomplete  breech,  thigh  variety. 

III.  Abdomen. — 

1.  Variety  of  the  right  flank. 

2.  Left  flank. 

3.  Lumbar  regions. 

4.  Umbilicus. 


FlG.  125. — Incomplete  breech,  knee  varrety. 

Thus,  as  for  the  thorax,  the  variety  is  constituted  by  the  region 
of  the  abdomen  (anterior,  posterior,  right  or  left  lateral)  presenting. 


ntations  and  Positions. 


103 


I  present  the  following  table,  placing  the  figures  relative  to  each 
presentation  and  their  varieties,  which  indicate  the  frequency. 


Fig.  126. — Incomplete  breech,  foot  variety. 


I.  Vertex,  956  per  1000. 


f  Occipital,          ... 
v    •             J    Frontal,            - 
variety,     -,    Right  Parietai> 

[  Left  parietal, 

-  (?) 

-  (?) 

-  (?) 

-  (?) 

II. 

Face,  4  per  1000. 

f  Mental,             ... 
,.                 J    Frontal,            ... 
Variety,     j   Right  makr>             .        . 

|^  Left  malar, 

•         (?) 

-  (?) 

-  (?) 

-  (?) 

Ill 

.  Brow,  4  per  1000. 

f  Parietal, 
v    -             J    Facial,      .... 
|    Right  temporal, 
[  Left  temporal, 

-  (?) 
"         (?) 

-  (?) 

-  (?) 

IV. 

Breech,  30  per  1,000. 

f  Complete,       ... 

v    .             |    Incomplete,  thighs, 
j    Incomplete,  knees, 
[  Incomplete,  feet, 

450  per  1000 
300    "      " 

5    "      " 
245    "      « 

V. 

Thorax,  6  per  1000. 

f  Risiht  shoulder, 

v    .             j    Left  shoulder, 

vanety,     j    g^      .... 

500  per  1000 

495    "      '• 
->    i<      (< 
0 

[  Sternum, 

2    "      " 

VI. 

Abdomen,  1  per  1000. 

f  Right  flank,      - 

Variety      \   Left  flank'   .    '        "        " 
- '      |    Lumbar  regions, 

[  Umbilicus, 

•  (?) 

•  (?) 

-  (?) 

-  (?) 

104  Presentations  and  Positions. 

Causes  of  the  presentations. — Accommodation,  or  adaptation  of 
the  contained  foetus  to  the  containing  uterus,  regulates  the  situation 
of  the  child  during  pregnancy.  The  laws  of  this  accommodation 
are  two  in  number  and  may  be  formulated  thus : 

First  law  (uterine  law). — Every  contractile  containing  body  adapts 
to  its  own  form  and  dimensions  its  contents  even  inert,  provided  it 
is  sufficiently  resisting  (that  is,  accommodation  can  be  made  with 
a  fcetus  recently  dead). 

Second  laic  (fcetal  law). — Every  living  contents,  endowed  with 
active  movements,  adapts  its  forms  and  dimensions  to  those  of  a 
containing  body  even  inert,  provided  it  is  sufficiently  resisting. 

Now,  these  two  essential  conditions  of  accommodation  wiU  be  re- 
united :  with  a  firm  and  contractile  uterus ;  with  a  vigorous  and 
moving  fcetus.  The  general  form  of  the  fcetus  is,  as  we  have  seen, 
that  of  an  ovoid,  with  the  large  extremity  corresponding  to  the 
breech,  the  small  extremity  to  the  head.  The  general  form  of  the 
uterus  is  that  of  an  ovoid,  with  the  large  extremity  corresponding  to 
the  fundus,  the  small  extremity  to  the  inferior  segment.  Accom- 
modation brings  the  breech  of  the  fcetus  to  the  fundus  of  the  uterus 
and  the  head  in  the  inferior  segment. 

We  now  know  why  the  fcetus  normally  presents  by  the  vertex. 
Let  us  review  the  various  causes  which  modify  this  physiological 
state  and  cause  other  presentations.  We  shall  need  to  examine 
successively  the  pelvis,  the  uterus,  the  ovuline  appendages  and  the 
accidental  causes,  such  as  traumatism. 

1.  Pelvis. — In  the  normal  state,  with  a  presentation  of  the  vertex, 
the  head  during  the  latter  part  of  pregnancy  engages  in  the  pelvic 
excavation.  This  engagement,  by  fixing  the  foetal  part,  assures  the 
preservation  of  the  presentation.  But  when  any  cause  (contraction 
of  the  pelvis,  pelvic  tumor)  renders  difficult  or  impossible  the  passage 
of  the  superior  strait,  the  head  remains  mobile  and  the  fcetus,  not 
being  fixed,  is  exposed  to  mutations  of  presentation. 

2.  Uterus. — Normal  accommodation  in  presentation  of  the  vertex 
supposes  a  uterus  sufficiently  resisting  and  of  an  ovoid  form  with 
the  small  extremity  inferior.  Any  exaggerated  flexibility  of  the 
uterus,  or  any  alteration  of  its  normal  form,  becomes  a  cause  of 
vicious  presentations. 

By  this  mechanism  act : 

Excessive  multiparity;  by  causing  a  relaxation  of  the  uterine 
wall,  and  of  the  abdominal  wall  which  sustains  it.  The  foetus  re- 
mains mobile  to  the  moment  of  delivery,  and  in  one  of  its  evolutions 
may  become  fixed  in  a  vicious  presentation. 

Lateral  and  anterior  inclinations  of  the  uterus ;  these  inclinations, 
whether  real  or  apparent,  involve  the  foetus  in  their  deviation,  so 
that  its  axis  no  longer  corresponds  with  that  of  the  pelvis.  The 
result  is  seen  in  vicious  presentations. 


Presentations  <unl  Positions. 


105 


Bifidity  of  the  fundus  of  the  uterus,  the  vestige  of  a  double  uterus, 
causes,  when  it  is  marked,  presentation  of  the  thorax  or  abdomen. 
Less  pronounced  bifidity  produces  either  a  breech  presentation  or 

one  of  the  three  presentations  of  the  cephalic  ovoid,  on  account  of 
the  direction  of  the  pressure  on  the  vertebral  column.  I  shall 
explain:  The  head  being  articulated  with  the  vertebral  column  so 
that  the  point  of  the  occiput  and  the  chin  are  at  an  equal  distance 
from  the  vertebral  foramen,  when  the  pressure  transmitted  by  the 
vertebral  column  to  the  head  is  made  in  the  direction  of  the  occiput, 
the  cephalic  extremity  is  flexed  (vertex  presentation) ;  it  is  extended, 
on  the  contrary,  when  this  pressure  is  directed  toward  the  chin 
(face  presentation) ,  and,  finally,  it  remains  intermediate  between 
flexion  and  extension  when  the  pressure  is  directed  toward  an  inter- 
mediate point,  the  forehead  (brow  presentation)  (Figs.  127, 128, 129). 


Fig.  127.  Fig.  128.  Fig.  129. 

Fig.  127. — Genesis  of  the  vertex  presentation.  Fcetus  in  L  O  I  T.  Breech  fixed  in 
the  right  cornu.     Pressure  of  the  vertebral  column  transmitted  toward  the  occiput. 

Fig.  128. — Genesis  of  the  face  presentation.  Foetus  in  LOIT.  Breech  fixed  in 
the  left  cornu.     Pressure  of  the  vertebral  column  transmitted  toward  the  chin. 

Fig.  129. — Genesis  of  the  brow  presentation.  Foetus  in  LOIT.  Breech  fixed  on 
the  median  line  cf  the  abdomen.  Pressure  of  the  vertebral  column  transmitted  toward 
the  brow. 

A  reverse  development  of  the  uterus,  that  is,  of  the  inferior 
segment  greater  than  that  of  the  fundus,  giving  the  form  of  an  ovoid 
with  its  large  extremity  below,  causes  a  breech  presentation. 
Finally,  tumors  of  the  uterus  or  in  its  vicinity,  altering  its  normal 
form,  may  be  the  source  of  vicious  presentations. 

3.  Foetus. — Any  cause  altering  the  general  form  of  the  fcetus,  or 
diminishing  its  volume  or  its  resistance,  is  susceptible  of  producing 
a  vicious  presentation.  We  find  in  this  category  of  causes  :  Death 
of  the  fcetus  when  it  dates  from  some  previous  time  and  when  macer- 
ation has  taken  place — accommodation  then  fails  to  act ;  smallness 
of  the  fcetus  also  renders  accommodation  useless.     Hydrocephalus, 


106  Presentations  and  Positions. 

increasing  the  size  of  the  head  relative  to  that  of  the  breech,  is  a 
cause  of  presentation  of  the  breech.  Dolichocephalus  has  been 
regarded  by  Hecker  as  a  cause  of  presentation  of  the  face,  but  it 
is  demonstrated  to-day  that  dolichocephalus  is,  except  in  some 
cases,  secondary  to  delivery  by  the  face,  and  is  not  primary. 
Exaggerated  size  of  the  foetal  head  will  be,  according  to  Spiegelberg, 
a  cause  of  face  presentation.  This  explanation  is  quite  admissible, 
for  it  acts  the  same  as  a  narrowing  of  the  pelvis.  Some  tumors  of 
the  foetus,  tumors  of  the  neck,  or  of  the  occiput,  causing  extension 
of  the  head  and  obstructing  descent,  may  also  produce  brow  or 
face  presentations.  Among  the  exceptional  causes  of  vicious 
presentations,  are  found  muscular  retractions  (congenital  torti- 
colis).  I  simply  mention  multiple  pregnancy  and  monstrosities. 
Their  influence  on  accommodation  will  be  easily  comprehended. 

4.  Ovuline  appendages. — Three  causes  on  the  part  of  the  ovuline 
appendages  may  produce  vicious  presentations  :  Placenta  praevia 
by  preventing  engagement  of  the  vertex  thus  favors  a  breech  or 
thorax  presentation.  Hydranmios,  by  distending  the  uterus, 
prevents  accommodation.  In  such  cases  breech  or  thorax  presen- 
tations are  frequently  seen.  Finally,  loops  of  the  cord  around  the 
fcetal  neck  may  retain  the  head  of  the  child  toward  the  fundus. 

5.  Traumatism. — Traumatism  acting  on  the  hypogastrium,  may 
displace  the  fcetal  head  and  be  the  source  of  a  vicious  presentation. 
This  cause  may  be  admitted,  but  it  is  wholly  exceptional. 

Peculiarities  of  each  presentation. — Presentations  are  definitive  or 
temporary,  according  as  the  foetal  part  is  fixed  or  momentarily 
arrested  in  the  genital  canal. 

In  general,  the  definitive  presentations  are  those  where  engage- 
ment has  taken  place  during  pregnancy,  and  the  temporary  those 
on  the  contrary,  where  the  fcetal  part  remains  mobile  at  the 
superior  strait.  We  shall  see,  however,  that  there  are  some  ex- 
ceptions. 

Vertex. — In  the  absence  of  an  abnormal  condition,  when  there 
is  a  vertex  presentation,  engagement  occurs  during  the  last  three 
months  in  the  primiparae,  and  during  the  last  fifteen  days  in  the 
multiparas     With  engagement,  the  presentation  becomes  definitive. 

Face. — Presentations  of  the  face  are  exceptional  during  preg- 
nancy ;  however,  some  cases  have  been  observed.  Ordinarily  they 
occur  at  the  moment  of  labor.  Presentations  of  the  face  existing 
during  pregnancy,  are  called  primary.  The  secondary  are  those 
formed  during  labor.  These  presentations  become  definitive  only 
when  engagement  occurs,  that  is  at  an  advanced  period  of  labor, 
for  engagement  never  takes  place  during  pregnancy  nor  at  the 
beginning  of  labor. 


Presentations  and  Positions.  107 

Brow. — What  has  been  said  with  regard  to  face  presentations, 
exactly  applies  to  those  of  the  brow. 

Breech. — Presentation  of  the  breech,  like  that  of  the  vertex,  may 
exist  long  before  labor.  During  pregnancy  there  may  be  observed 
a  complete  presentation  of  the  breech  or  an  incomplete,  of  the 
variety  of  the  thigh;  the  two  other  varieties  (knees  and  feet)  only 
appear  at  the  moment  of  labor.  When  the  breech  is  incomplete, 
thigh  variety,  it  often  engages  in  the  last  part  of  pregnancy,  and  by 
this  engagement  becomes  definitive.  But  when  the  breech  is 
complete,  its  volume  prevents  engagement;  and  yet  the  presen- 
tation is  often  definitive  without  engagement,  for  the  cause  which 
produces  tins  vicious  presentation  prevents  the  foetus  from  changing 
its  position.  In  this  case,  as  in  the  preceding  with  engagement, 
there  are  sometimes  found  serious  difficulties  in  performing  version 
by  external  manoeuvres. 

Thorax. — Presentations  of  the  thorax  exist  during  pregnancy  as 
at  the  moment  of  labor,  but  they  are  rarely  definitive  during  ges- 
tation, unless  a  special  form  of  the  uterus  fixes  the  foetus  in  this 
vicious  situation.  The  engagement  of  the  shoulder  (much  the  most 
frequent  variety)  never  occurs  during  pregnancy,  and  only  takes 
place  at  an  advanced  period  of  labor.  At  this  moment,  or  when 
after  the  flow  of  the  liquor  amnii  the  uterus  is  retracted,  the  presen- 
tation becomes  definitive,  and  is  much  more  difficult  to  correct,  as 
considerable  time  has  elapsed. 

Presentations  of  the  abdomen  are  subject  to  the  same  consider- 
ations as  those  of  the  thorax. 

Positions. — When  we  examine  completely  and  in  detail  a  statue 
placed  on  a  mobile  pedestal,  we  turn  it  to  note  successively  the 
face,  the  three-quarter  view  (anterior),  the  profile,  the  three-quarter 
(posterior),  the  back;  then,  by  continuing  the  movement  of  rotation, 
the  three-quarter  view  (posterior),  the  profile,  the  three-quarter 
(anterior),  and  finally  the  face,  the  statue  now  having  returned  to 
the  starting  point.  Now,  the  foetus,  whatever  may  be  the  presen- 
tation, may  execute  in  the  uterine  cavity  an  analogous  evolution, 
an  evolution  during  which,  without  changing  the  presentation,  it 
will  offer  a  series  of  new  situations.  To  those  different  situations 
we  give  the  name  of  positions.  The  importance  of  clearly  dis- 
tinguishing positions  from  presentations  is  then  seen.  The  presen- 
tation is  constituted  by  the  foetal  region  which  descends  first  into 
the  parturient  canal.  The  position  is  the  situation  of  the  foetal 
region  which  presents.  We  know  the  presentations,  let  us  study 
the  positions. 

To  designate  the  different  positions,  there  has  been  chosen  for 
each  presentation  a  foetal  point  or  land-mark,  which,  by  its  relations 


108 


Presentations  and  Positions. 


with  other  points  taken  on  the  parturient  canal,  permits  the 
determination  of  the  exact  situation  of  the  child.  I  shall  explain 
by  an  example  :  A  foetus  presents  by  the  vertex  (I  take  the  occiput 
as  a  landmark),  the  occiput  may,  according  to  the  situation  of  the 
child,  be  in  relation  with  the  pubis,  with  the  sacrum,  or  with  other 
regions  of  the  pelvic  ring,  thus  we  should  have  an  occipito-pubic 
position  (contact  of  the  fcetal  occiput  and  the  maternal  pubis),  an 
occipito-sacral  (contact  of  the  foetal  occiput  with  the  maternal 
sacrum),  etc. 
1. — Foetal  points, 

I.  Vertex        -        -        Occiput 
II.  Face  -        -        Mentum 

III.  Brow.  -        -        Mentum 

IV.  Breech        -        -        Sacrum 
V.  Thorax        -        -        Acromium 

VI.  Abdomen    -        -        Acromium 


0. 

M. 

M.  (Id.  as  for  face). 

S. 

A. 

A.  (Id.  as  for  thorax). 


LIT* 


•  RU 


Fig.  130. — Rosette  of  positions. 

2.  Maternal  points. — There  have  been  taken  on  the  contour  of  the 

pelvic  ring  the  terminal  points  of  the  different  diameters.     These 
points  are  the  following : 

Point. — Pubic P. 

Right  anterior  iliac  -  -  -  E  A  I. 
Right  transverse  iliac    -        -        -        RTI. 

Right  posterior  iliac       -        -        -        E  P  I. 

Sacral S. 

Left  posterior  iliac  -  -  -  L  P  I. 
Left  transverse  iliac  -  -  -  L  T  I. 
Left  anterior  iliac  -        -        -        LAI. 


Presentations  and  Positions.  109 

As  a  whole  these  points,  in  comparison  with  a  mariner's  eomp 
may  be  called  the  compass  of  the  positions. 

Now  for  each  position  lei  as  put  the  fcetal  point  in  relation  with 
different  maternal  points  and  we  shall  have  the  series  of  positions 
which  follow : 

I.  Vertex  (Occiput). — O. 

Position. — Occipito-pubic 

Right  anterior  occipito-iliac 
Right  transverse  occipito-iliac 
Right  posterior  oceipito-iliac 
Occipito- sacral 
Left  posterior  oceipito-iliac 
Left  transverse  occipito-iliac 
Left  anterior  occipito-iliac 

II.  Face  (Mention).— M. 

Position. — Mento-pubic 

Pdght  anterior  niento-iliac  - 

I.  Vertex  [Occiput). — 0. 

Position. — Occipito-pubic 

Eight  anterior  occipito-iliac    - 
Pdght  transverse  occipito-iliac 
Pdght  posterior  occipito-iliac 
Occipito- sacral 

Left  posterior  occipito-iliac  - 
Left  tranverse  occipito-iliac  - 
Left  anterior  occipito-iliac 

II.  Face  (Mention). — M. 

Position. — Mento-pubic 

Right  anterior  niento-iliac 

Plight  transverse  mento-iliac  - 

Plight  posterior  niento-iliac 

Mento-saeral 

Left  posterior  mento-iliac 

Left  transverse  mento-iliac    - 

Left  anterior  mento-iliac 

III.  Brow  (Mention).— M. 
LI.  as  for  the  face. 

IV.  Breech  {Sacrum). — 8. 

Position. — Sacro-pubic    -        -        -        -         S  P. 

Plight  anterior  sacro-iliac        -         I!  S  I  A  3. 

*The  figure  following  the  oblique  positions  indicates  their  relative  frequency,  the 
figure  I  representing  the  most  frequent,  which  has  been  called  the  first  position  of  the 
vertex. 


OP. 

Pi  0  A  I  3.* 

R  T  0  I. 

Pi  0  P  I.  2 

OS. 

L  0  P  I  4. 

L  0  T  I. 

L  0  A  I  1. 

M  P. 

R  M  A. 

OP. 

Pi  0  I  A  3.* 

Pi  0  I  T. 

Pi  0  I  P  2. 

0  S. 

L  (J  I  P  4. 

L  01  T. 

L  0  I  A  1. 

M  P. 

Pi  M  I  A. 

E  M  I  T. 

Pi  M  I  P. 

M  S. 

LM.IP. 

L  M  I  T. 

L  M  I  A. 

110 


Presentations  and  Positions. 


Eight  transverse  sacroiliac    -  E  S  I  T. 

Eight  posterior  sacro-iliac       -  E  S  I  P  2. 

Sacro-sacral  -         -         -  S  S. 

Left  posterior  sacro-iliac        -  L  S  I  P  4. 

Left  transverse  sacro-iliac      -  L  S  I  T. 

Left  anterior  sacro-iliac         -  L  S  I  A  1. 

V.  Thorax  (Acromium). — A. 

Position. — Acromio-pubic       -        -        -  A  P. 

Eight  anterior  acromio-iliac  -  E  A  I  A.* 

Eight  transverse  acromio-iliac  E  A  I  T. 

Eight  posterior  acromio-iliac  -  E  A  I  P. 

Ac  rornio- sacral      -        -        -  AS. 

Left  posterior  acromio-iliac    -  L  A  I  P. 

Left  transverse  acromio-iliac  L  A  I  T. 

Left  anterior  acromio-iliac    -  L  A  I  A. 


VI.  Abdomen  (Acromium)  .- 
Id.  as  for  the  thorax. 


-A. 


Fig.  131.— LOIT. 

To  render  complete  and  intelligible  this  enumeration  of  the 
positions  in  the  different  presentations,  I  have  adjoined  a  series  of 
illustrations  showing  the  situation  of  the  foetus  in  these  different 
cases  (except  the  brow  presentations  which  take  the  same  situations 

*For  the  frequency  of  the  positions  of  the  thorax,  it  is  sufficient  to  know  that  the 
dorsoanterior  are  more  frequent  than  the  dorso  posterior. 


Presentations  and  Positions. 


Ill 


as  for  the  face,  by  Blightly  flexing  the  head  and  by  assuming  a 
position  intermediate  between  a  vertex  and  a  face  presentation  ;  and 
abdominal  presentations,  which  occupy  the  sami  situation  ae  for 
the  thorax,  by  Blightly  drawing  the  thorax  away  from  the  center  of 
the  genital  canal,  so  as  to  replace  it  by  the  abdomen). 


Fig.  132.— ROIT. 


Fig.  irv— LOIA. 


112 


Presentations  and  Positions. 


Fig.  134.— LOIP. 


Fig.  135.— ROIA. 


Pmn-ututions  and  Positions. 


118 


Fig.  136.— R  O I  P. 


Fig.  137. 


114 


Presentations  and  Positions. 


Fig.  139.— R  MIT. 


Presentations  and  Positions. 


115 


Fig.  140.— L  M  I  T. 


Fig.  141 —LM  I  A. 


116 


Presentations  and  Positions. 


Fig.  142.— L  M  I  P. 


Fig.  143  — R  M  I  A. 


Presentation-  and  Positions. 


117 


Fig.  144.— R  M  I  P. 


Fig.  145. 


118 


Presentations  and  Positions. 


Fig.  146. 


ntatwns  and  Positions. 


119 


Fie.  149.— LSI  A. 


120 


Presentations  and  Positions. 


Fig.  150.— LSI  P. 


Fig.  151.— RSI  A. 


Presentations  and  Positions. 


121 


Fig.  152.— RSI  P, 


Fig.  153—  L  SIT. 


1-22 


Presentations  and  Positions. 


Fig.  154.— R  SIT. 


Fig.  155— RAIT. 


I',-,  u  ntatio      and  Vowtwns. 


128 


Fig.  156.— LAI  T. 


Fig.  157.— LAI  A. 


124 


Presentations  and  Positions. 


Fig.  158.— LAI  P. 


Fig.  159.— RAIA. 


Presentations  and  Positions. 


125 


126 


Presentations  and  Positions. 


^Etiology  of  the  positions.  —  Vertex.  —  The  two  most  frequent 
positions  are,  first,  L  0  I  A,  then  EOIP.  It  has  been  asked  why 
the  long  diameter  of  the  head  voluntarily  occupies  the  oblique 
cecal  diameter,  and  it  has  been  replied  that  this  diameter  is  greater 
than  the  rectal  or  that  the  distention  of  the  rectum  diminishes  the 
latter.  But  this  explanation,  which  is  only  an  hypothesis,  is  not 
satisfactory.  It  is  probable  that  the  head  is  found  to  occupy  the 
oblique  caeeal  diameter  on  account  of  the  more  marked  development 
of  the  right  cornu  of  the  uterus.  With  regard  to  the  predominance 
of  the  L  0  I A  in  relation  to  the  EOIP,  it  responds  to  a  law  which 
regulates  all  the  presentations :  The  back  of  the  fcetus,  on  account 
of  the  projection  of  the  vertebral  column  posteriorly,  is  better 
accommodated  to  the  anterior  part  of  the  uterus  than  to  the 
posterior.  I  only  speak  here  of  the  aetiology  of  the  oblique  positions, 
as  they  are  the  only  ones  authors  generally  treat  of.  The  transverse 
and  the  direct  positions  are  governed  like  the  oblique  by  the  form 
of  the  pelvis. 

Face,  Brow. — Presentations  of  the  face  being  only  transformations 
of  those  of  the  vertex,  the  same  etiological  considerations  apply  to 
the  positions. 

Breech. — The  breech  only  rarely  engaging  during  pregnancy  the 
question  of  the  extent  of  the  pelvic  diameters  is  only  secondary. 


Symptomatology  of  Pregnancy.  1^7 

head  Lodging  in  the  right  cornet,  the  back  will  be  placed  to  the 
1.  it  and  in  front  or  to  the  right  and  ln-hind. 

Thorax,  Abdomen. — During  pregnancy  transverse  positions  are 
Bcarcely  ever  found.  According  to  the  general  rule  the  back  is 
u-ually  found  to  the  front,  in  such  a  manner  that  for  the  Left 
shoulder  the  RAIT  is  observed  and  the  LA  IT  for  the  right 
shoulder.     The  accommodation  of  the  hack  is  the  cause. 


CHAPTER  VI 


SYMPTOMATOLOGY  OF  PREGNANCY. 

The  symptoms  and  signs  of  pregnancy  may  he  divided  into  two 
great  classes  :  those  which  depend  on  the  genital  system,  and  those 
which,  on  the  contrary,  are  independent.  "We  have,  then:  1.  The 
extra-genital  symptoms.     2.  The  genital  symptoms. 

I.  Extra-genital  symjrtoms.  —  The  modifications  of  the  different 
systems  (nervous,  respiratory,  circulatory,  digestive,  etc)  have 
been  previously  studied,  and,  to  avoid  useless  repetitions,  I  shall 
not  return  to  them. 

II.  Genital  symptoms. — In  examining  the  pregnant  woman  we 
proceed  successively  to : 

1.  Interrogation. 

•2.  Inspection. 

3.  Palpation  (and  to  percussion). 

-J    Auscultation. 

5.  Digital  examination. 

I  shall  conform  to  this  order  in  the  study  of  the  symptoms  of 
pregnancy.  The  symptoms  furnished  by  interrogation  respond 
very  nearly  to  those  designated  as  rational,  and  those  of  the  four 
other  categories  to  the  physical  signs. 

1.  Interrogation. — The  information  that  the  woman  can  furnish 
as  to  the  sexual  relations,  the  actual  cause  of  pregnancy,  will  rarely 
be  of  any  use.  Their  ahsence  in  eases  of  doubtful  diagnosis,  or 
their  isolated  existence  at  a  fixed  date,  when  it  relates  to  a  precise 
statement  of  the  epoch  of  pregnancy,  will  be  the  only  points  to  seek, 
and  on  these  points  the  confidence  in  feminine  veracity  >hould  be 
limited. 


128  Symptomatology  of  Pregnancy. 

From  menstruation,  on  the  contrary,  may  be  deduced  signs  of 
great  value. 

Every  arrest  of  menstruation  in  a  healthy  woman,  normally 
regular,  should  bring  to  mind  the  possibility  of  the  existence  of 
pregnancy 

Conception  may  take  place  at  any  period  of  the  inter-menstrual 
period  or  during  the  menstrual  flow,  but  in  the  majority  of  cases  it 
occurs  during  the  ten  days  following  the  end  of  menstruation. 
From  this  moment  of  conception  the  menstrual  flow  doi'S  not 
appear.  There  are,  however,  exceptions,  and  some  women  continue 
to  menstruate  during  pregnancy.  It  has  been  objected  that 
menstruation  during  pregnancy  is  modified  in  duration,  quantity  or 
quality.  But,  practically,  the  woman  reports  a  periodical  flow  of 
the  same  abundance  and  quantity  as  before  pregnancy.  There  is 
then  nothing  to  show  that  this  flow  of  blood  differs  from  normal 
menstruation.  It  is  just  to  conclud  that  this  woman  is  menstruating 
but  it  must  not  be  deduced  that  the  uterus  is  empty.  Conclusion: 
If  the  cessation  of  menstruation  is  one  of  the  best  signs  of  the  be- 
ginning of  pregnancy,  we  must  not  base  an  affirmation  of  the 
vacuity  of  the  uterus  on  its  persistence. 

The  development  of  the  abdomen  is  only  perceived  by  the  woman 
at  the  end  of  a  certain  stage  of  pregnancy  (two  months  and  some- 
times even  more).  Soon  after  conception,  some  women  perceive  a 
certain  flattening  of  the  abdomen.  The  development  of  the  ab- 
domen, generally  perceived  clearly  at  the  end  of  the  fourth  month, 
rarely  progresses  with  regularity.  All  other  tilings  being  equal,  the 
development  of  the  abdomen  is  as  much  more  considerable  as  the 
number  of  pregnancies  becomes  greater — a  fact  explained  by  the 
increasing  laxity  of  the  abdominal  walls. 

We  shall  ignore  the  exact  date  at  which  the  first  movements  of 
the  child  are  perceived,  but  we  know  that  they  are  generally  felt  at 
the  beginning  of  the  fourth  month.  In  general,  it  is  at  four  months 
and  a  half  that  these  movements  are  perceived,  sometimes  later. 
Some  pregnant  women  never  feel  them. 

The  descent  of  the  uterus  resulting  from  engagement  causes  pelvic 
obstruction  (frequent  urging  to  urination,  exaggeration  of  the  con- 
stipation) and  a  thoracic  relief  (easier  respiration).  At  the  same 
time  the  abdomen  seems  to  diminish  in  volume.  Women  usually 
can  give  quite  exact  information  on  these  different  symptoms. 

2.  Inspection. — The  inspection  of  the  abdomen  and  of  the  ex- 
ternal genital  organs  reveals  a  series  of  modifications,  that  have 
already  been  discussed  and  which  I  only  recall  here.  On  the  side 
of  the  abdominal  wall,  besides  the  distention  produced  by  the  in- 
crease in  the  size  of  the  uterus,  are  noted  the  linear  albicantes,  es- 
pecially numerous  in  the  subumbilical  region,  and  the  brownish 


Symptomatology  of  Pregnancy.  129 

pigmentation  along  the  linea  alba.  The  external  genital  org 
besides  oedema  and  varices,  undergo  a  hypertrophy  which  give  them 
a  swollen  aspect.  The  vestibule  and  th  •  vulvo- vaginal  orii 
a  violaceous  coloration  thai  is  also  found  i  a  the  vagina  and  cervix 
by  using  a  Bpeculum.  This  coloration  sometimes  aids  the  diag- 
nosis of  pregnancy,  bui  it  is  nol  pathognomonic.  Besides  this, 
there  is  found  sometimes  in  brunettes  a  diffuse  pigmentation  of  the 
vulva,  especially  marked  on  the  labia  majora. 

3.  Palpation. — Percussion  is  a  variety  of  palpation  but  while 
it  occupies  a  considerable  place  in  medicine,  its  part  is  of  slight 
importance  in  obstetrics.  Percussion  can  only  serve  to  give  infor- 
mation as  to  the  height  of  the  uterus  and  on  the  contents  of  normal 
or  pathological  organs  situated  around  or  in  front  of  the  uterus.  I 
shall  not  insist  on  these  secoudary  ideas  hut  pass  at  once  to  pal- 
pation itself. 

For  palpation  the  woman  should  be  disrobed,  preserving  no 
garment  that  will  obstruct  abdominal  palpation.  Save  in  rare  ex- 
ceptions the  horizontal  decubitus  is  indispensable,  the  head  a  little 
elevated,  the  limbs  extended  and  slightly  separated  from  each  other, 
the  arms  stretched  along  the  body,  all  the  muscles  being  relaxed  as 
much  as  possible.  The  obstetrician  should  have  warm  huids,  for 
a  cold  contact  predisposes  to  muscular  contraction.  The  physician 
places  himself  to  the  right  of  the  patient  and  proceeds  with  extreme 
slowness. 

,  The  palpation  consists  of  three  portions:  (A).  Prauterine,  in 
which  the  abdominal  wall  and  the  organs  around  the  uterus  are 
explored ;  (B)  The  uterine,  where  the  walls  of  the  uterus  arc- 
examined  ;  (C)  The  infra-uterine,  in  which  the  contents  of  the  uterus 
are  in  question,  that  is  the  ovum  itself  in  the  case  of  pregnancy. 
Let  us  examine  each  of  these  in  succession : 

A.  Prteuterine.  —  The  thickness  of  the  abdominal  wall  will  he 
appreciated  by  pinching  it  up  in  front  of  the  uterus.  Pra^uterine 
palpation  affords  information  as  to  the  presence  of  intestinal  loop- 
in  front  of  the  uterus,  on  the  degree  of  distention  of  the  bladder, 
when  this  reservoir  exceeds  the  superior  strait.  In  this  pra?uterine 
exploration,  the  fingers  will  often  feel  the  round  ligaments,  forming 
a  cord  quite  clearly  perceptible  during  pregnancy,  especially  when 
it  is  the  seat  of  varices,  and  sometimes  one  of  the  ovaries.  In  this 
exploration  will  be  recognized  the  tumors  developing  at  the  expense 
of  the  abdominal  organs. 

B.  Uterine. — By  following  the  contour  of  the  uterus,  its  height 
above  the  symphysis  or  above  the  umbilicus  will  lie  determined,  an 
important  observation  in  determining  the  date  of  the  pregnancy, 
and  its  inclination  to  one  side  or  the  other  of  the  abdomen  will  be 
recognized.     Supple  in  a  normal  state,  the  uterine  wall  becomes 


130  Symptomatology  of  Pregnane}/. 

resistant  during  contraction.  In  cases  of  excessive  softness  of  the 
uterus,  this  contraction  hecomes  necessary  to  afford  a  clear  contour 
of  the  organ  and  to  reveal  the  peculiarities  of  its  conformation.  By 
palpation  the  approximate  thickness  of  the  uterine  wall  can  he 
determined.  This  is  especially  to  be  appreciated  by  the  degree  of 
the  distance  of  the  foetal  part.  Some  uterine  walls  appear  so  thin 
by  the  superficiality  of  the  foetus  as  to  give  the  impression  of  an 
extra-uterine  pregnancy.  Uterine  exploration  also  affords  infor- 
mation on  the  existence  of  malformations  and  on  the  presence  of 
fibroids.  The  latter,  when  of  small  size,  may  be  mistaken  for 
foetal  parts,  but  their  immobility  and  their  preception  during  uterine 
contraction  will  avoid  an  error  of  diagnosis. 

C.  Intro-uterine. — We  arrive  at  the  exploration  of  the  uterine 
contents,  which  constitutes  the  third  and  the  most  important 
portion  of  palpation.  In  palpation  of  the  ovum,  many  of  the  sen- 
sations imparted  by  the  foetus  are  exact,  many  of  those  given  by 
the  appendages  (placenta,  cord,  amniotic  liquid)  are  vague.  In 
exceptional  cases  it  is  possible  that  a  special  doughiness  may  sepa- 
rate the  fingers  from  the  fcetal  plane,  this  supposes  a  placenta  at 
this  point.  I  have  never  felt  such  a  sensation.  When  the  abdomi- 
nal wall  is  very  thin  the  fingers  may  meet  a  cord  surrounding  the 
fcetal  trunk.  The  liquor  amnii  in  normal  quantity  gives  a  fluctu- 
ation as  a  whole  analogous  to  that  obtained  at  the  surface  of  a  large 
abscess.  The  foetus,  however,  is  the  principal  aim  of  our  explo- 
ration, and  the  hands,  separated  from  it  by  the  utero-abdominal 
wall,  should  become  familiar  with  it.  Before  going  further  in  this 
study,  it  is  important  to  note  two  important  signs  that  are  to  be 
considered  as  positive  signs  of  pregnancy.  I  speak  of  passive  move- 
ments and  of  active  movements  of  the  foetus.  The  first  attest  the 
presence  of  a  foetus  and  the  second  indicate  that  the  child  is  living. 
The  first -is  furnished  by  preference  by  the  foetal  head,  the  second 
by  the  thoracic  members  and  especially  by  the  pelvis. 

1.  Passive  movements. — Usually  designated  as  balottement  these 
movements  are  produced  in  the  following  conditions  (I  suppose  the 
foetal  head  at  the  fundus  of  the  uterus,  two  or  three  fingers  are 
applied  mediately  at  its  point  of  contact) :  a.  A  sudden  concussion 
is  .iven  to  the  fcetal  head  by  depressing  the  abdominal  wall;  the 
fingers  receive  the  sensation  of  a  distant  flying  body — single  sen- 
sation (of  departure),  h.  Often,  the  hand  being  left  in  place,  at 
tlif  end  of  a  few  seconds  the  head  returns  to  its  first  position  and 
imparts  a  shock  to  the  fingers — double  sensation  (of  departure  and 
of  return),  c.  If  the  two  hands  are  applied  to  the  lateral  extrem- 
ities of  the  head,  the  fcetal  head  pushed  suddenly  by  one  hand  gives 
a  sensation  of  departure,  comes  against  the  other  hand,  a  second 
sensation  of  shock,  and  then  returns  to  its  first  position,  giving  a 


Symptomatology  of  Pregnancy,  181 

third  shock  treble  Bensation  (of  departure,  of  Bhock.  and  of  return). 
Such  are  the  varieties  of  balottement,  I  add  abdominal,  for  we  will 
later  that  there  exists  a  vaginal. 

Balottement  constitutes  a  positive  sign  of  pregnancy,  on  one  con- 
dition, which  is  that  the  tumor  giving  this  sensation  must  be  intra- 
uterine. This  condition  is,  in  fact,  indispensable,  for  it  sometimes 
happens  thai  abdominal  tumors  may  float  in  an  ascitic  fluid.  I 
have  met  two  cases  of  abdominal  tumors  producing  ballottement, 
but  these  tumors  are  never  intra-uterine.  Every  intra-uterine  tumor 
which  imparts  the  sensation  of  ballottement,  indicates,  then,  with 
certainty,  the  presence  of  a  foetus. 

2.  Active  movements. — By  applying  the  hands  for  some  time  on 
the  abdominal  wall  there  are  felt  slight  shocks  produced  by  the  feet 
i  if  the  foetus  uplifting  the  utero-abdominal  wall,  more  rarely  by  other 
foetal  parts.  These  movements  are  often  perceptible  to  vision. 
Besides  these  slight  shocks  the  hand  sometimes  perceives  a  more 
extended  movement,  caused  by  the  displacement  of  the  foetus  as  a 
whole.  These  movements,  easily  perceptible  to  the  mother,  are 
often  a  cause  of  error  on  her  part  on  account  of  the  possible  con- 
fusion with  other  analogous  sensations ;  but  it  is  not  the  same  when 
they  are  perceptible  to  the  physician.  A  shock  clearly  perceived 
by  the  obstetrician  at  the  surface  of  a  tumor  of  the  abdomen,  with- 
out the  interposition  of  the  intestine  between  this  tumor  and  the 
abdominal  wall,  indicates  the  positive  presence  of  a  living  foetus. 

Active  movements,  perceived  by  the  obstetrician,  are,  then,  a 
positive  sign,  but  on  condition  of  the  absence  of  the  intestine,  for 
contractions  of  this  organ  may  sometimes  simulate  foetal  move- 
ments. Now,  percussion  easily  detects  the  presence  of  the  intestine 
by  its  sonorousness.  Muscular  contractions  of  the  abdomen  can 
not  simulate  fcetal  movements,  for  the  surface  of  their  production 
is  too  large.  I  add  in  conclusion  that  these  active  movements  to 
constitute  a  positive  sign  must  be  dearly  perceived.  Having 
studied  the  active  and  passive  movements  of  the  foetus,  let  us  pass 
in  review  the  details  of  the  peculiarities  of  fcetal  palpation. 

The  head  is  distinguished  by  its  hardness,  its  rounded  form  and 
its  mobility,  in  the  absence  of  engagement  in  the  pelvis.  The  last 
character  is  absent  when  the  head  is  fixed  in  the  pelvic  ring,  but 
the  other  characters  are  sufficient  then  for  its  recognition.  In  case 
of  doubt,  the  groove  constituted  by  the  neck  will  be  a  valuable 
mark  to  distinguish  the  head  from  the  breech. 

The  breech  is  regular  at  one  side  (buttocks),  irregular  at  the  other 
(pelvic  members).  It  appears  larger  than  the  head,  when  it  is 
complete  (thighs  flexed  and  close  to  the  body),  less  in  size,  on  the 
contrary,  when  it  is  incomplete.  Exceptionally  it  furnishes  the 
sensation  of  ballottement. 


132  Symptomatology  of  Pregnancy. 

The  thorax  and  the  abdomen  are  not  more  often  accessible  than 
the  back  of  the  foetus,  and  are  simply  revealed  by  a  certain  resist- 
ance to  the  exploring  hand.  Sometimes  the  crest  of  the  spinous 
apophyses  can  be  felt.  The  shoulder  will  be  recognized  by  the  pro- 
jection it  forms  in  the  vicinity  of  the  cephalic  extremity. 

AVith  regard  to  the  pelvic  or  thoracic  limbs,  outside  of  the  active 
movements  by  which  they  are  so  frequently  manifested,  they  appear 
in  the  form  of  a  tumor,  cylindrical  or  rounded,  easily  displaced. 


Epigastrium. 


Hypochondrium. 


Iliac  fossa. 


Hypogastrium.. 


Fig.  163. — Schematic  division  of  the  uterus  into  different  regions. 

With  this  knowledge  of  each  fcetal  part,  we  can  begin  the  study  of 
the  diagnosis  of  the  presentations  and  positions  by  the  aid  of  pal- 
pation. The  first  fcetal  part  that  should  be  sought,  on  account  of 
the  clearness  of  the  sensations  which  it  furnishes,  is  the  head. 
When  the  situation  of  the  head  can  be  exactly  stated,  fcetal  pal- 
pation is  three-quarters  completed.  Let  us  then  take  up  the 
search  for  the  cephalic  ovoid.  Fig.  163  shows  the  different  regions 
of  the  uterus,  each  corresponding  to  an  analogous  region  of  the 
abdomen.  Besides  the  umbilicus,  which  is  the  central  and  median 
region,  the  head  may  occupy  : 

1.  The  hypogastrium. 

2.  The  iliac  fossa  (right  or  left). 

3.  The  flank  (right  or  left). 

4.  The  hypochondrium  (right  or  left). 

5.  The  epigastrium. 

1.  The  head  in  the  hypogastrium  (mobile  or  engaged). — This  situation 
is  much  the  most  frequent,  for  the  hypogastrium  leads  to  the  partu- 
rient canal  and  vertex  presentations  are  the  rule.     The  head,  at  the 


Symptomatology  of  Pregnancy. 


L88 


hypogastrium,  may  be  found  in  two  \< .  y  different  conditions,  mobile 
above  the  superior  strait,  or  fixed  iii  the  parturienl  canal. 

When  the  head  is  mobile  at  the  level  of  the  superior  Btrait,  more 
or  Less  approached  to  it,  presentation  exists,  for  the  fceta]  part  is 

,-it  thr  entrance  to  the  genital  canal,  but  it  may  be  easily  modified, 
either  spontaneously  or  artificially.  When,  on  the  contrary,  the 
head  has  penetrated  into  the  pelvis,  the  presentation,  without  he- 
coming  absolutely  definite,  takes  a  stability  much  more  marked. 
Mel  die  at  the  superior  strait,  the  head  may  engage  by  the  vertex, 
face  or  brow.  Thus  it  is  impossble  to  exactly  state  in  advance 
whichone  of  these  presentations  will  become  definitive  at  the  moment 
of  engagement.  The  obstetrician  must  then  be  contented  to  say  in 
such  eases,  presentation  6f  the  cephalic  ovoid.  But  when  the  head 
has  penetrated  into  the  excavation,  mutations  of  presentations  are 
rare,  so  that  at  this  moment,  save  some  restrictions,  an  exact  diag- 
nosis becomes  possible. 


Fig.  164 — Search  for  the  head  in  the  hypogastrium. 

Let  us  examine  these  different  cases.  To  seek  the  head  in  the 
hypogastrium,  the  hands  are  applied  as  in  Fig.  164.  At  about  rive 
centimetres  above  the  superior  strait,  one  seeks,  by  approaching 
the  extremities  of  the  fingers  of  the  two  hands,  to  grasp  the  body 
which  may  lie  interposed  between  them.  If  the  head  is  found  at 
this  level  its  characters  are  revealed  and  it  will  he  more  or  less 


134 


Symptomatology  of  Pregnancy. 


mobile.  If  the  head  is  riot  met  in  this  first  exploration  the  extrem- 
ities of  the  fingers  are  depressed  a  little  ;  the  superior  strait  is  then 
sought  and,  at  need,  even  the  excavation.  If  the  head  is  at  this 
level  we  find  :  A.  Presentation  of  the  vertex.  B.  Presentation  of 
the  brow.  C.  Presentation  of  the  face.  (The  last  two  exist  at  the 
moment  of  labor). 


Fig.  165. —  Search  for  the  engaged  head  in  presentation  of  the  vertex  (Pinard). 

A.  Presentation  of  the  vertex. — On  one  side  the  hand  finds  with 
difficulty  the  resisting  plane  furnished  by  the  head  ;  on  the  other  it 
is  quickly  arrested  by  a  projecting  tumor,  clearly  appreciable  (Fig. 
165).  The  part  of  the  head  difficult  to  find  is  the  occiput,  the  other 
projecting,  easily  explored,  is  the  forehead.  According  as  the  pro- 
jection is  more  or  less  marked,  the  exploring  hand  will  note  whether 
the  forehead  is  turned  posteriorly,  transversely  or  anteriorly. 
This  simple  exploration,  made  with  precision,  permits  the  recog- 
nition of  both  the  presentation  and  the  position.  Exploration  of  the 
trunk,  which  will  be  explained  later,  will  complete  this  diagnosis. 

B.  Brow  presentation. — On  one  side  is  a  voluminous  tumor,  more 
projecting  than  the  forehead  in  vertex  presentation  and  here  con- 
stituted by  the  occiput  (Fig.  166).  On  the  other  side  is  an  unequal 
tumor  'jiving  sensation  of  an  incomplete  clearness.  This  is  the  in- 
ferior part  of  the  face  and  neck. 

C.  Face  presentation. — On  one  side  is  a  projection,  relatively 
large,  seemingly  constituting  by  itself  all  the  foetal  head;    this  is 


Symptomatology  of  Pregnancy. 


IBS 


the  occipito-parietal  projection,  the  same  as  found  in  brow  presen- 
tations but  exaggerated  by  the  extension  of  the  head  (Fig.  107). 


Fig.  166. — Brow  presentation  with  head  engaged. 


Fig.  167. — Face  presentation  with  head  slightly  engaged. 


136 


Symptomatology  of  Pregnancy. 


This  projection  is  separated  from  the  trunk  by  a  very  clear  de- 
pression. On  the  opposed  side  the  face  is  explored  with  difficulty, 
though  in  cases  of  rnento-anterior  the  inferior  maxillary  constitutes 
at  this  point  a  sort  of  horseshoe. 

If  we  compare  the  three  presentations  of  the  cephalic  ovoid,  we 
see  that  palpation  of   the  head   gives  a   projection  much-  more 
marked  on  one  side  than  on  the  other. 
Projecting  side  of  the  head. — 

Vertex. — Frontal  region. — Marked  projection. 
Brow.— Occipital  region. — More  marked  projection. 
Face.— Occipito-parietal  region. — Very  large  projection. 
Retreating  side  of  the  head. — 

Vertex. — Occipital  region. — Smooth. 

Brow. — Face  and  neck. — Uneven. 

Face. — Contour  of  inferior  maxillary. — Uneven. 


Fig.  168. — Thorax  presentation;   variety;  left  shoulder. 

In  proportion  as  the  head  descends  into  the  parturient  canal,  ex- 
ploration becomes  more  difficult.  Finally,  at  a  given  moment 
during  labor,  the  head  becomes  no  longer  accessible  to  palpation. 

After  having  recognized  and  determined  the  situation  of  the 
head,  it  is  necessary  to  explore  the  breech  and  the  back  to  complete 
tin-  palpation.  The  breech  is  found  in  one  or  the  other  hypo- 
chondrium,  in  general  in  that  which  corresponds  to  the  brow  (with 
vertex  presentation),  rarely  on  the  median  line  at  the  epigastrium. 
The  buck,  according  as  we  have  to  do  with  a  vertex,  a  brow,  or  a  face 
-entation,  will  be  found  more  or  less  approached  to  the  uterine 


Symptomatology  of  Pregnancy. 


L87 


wall.     Palpation  of  the  Bhoulder  may  aid  in  completing  a  doubtful 
or  difficult  diagnosis  in  Borne  cases. 


FlG.  169. —  Presentation  nul  (breech  and  head  in  the  flanks). 


Fig.  170. — Abdomen  presentation  (breech  in  the  iliac  fossa  and  head  in  the  flank). 

•2.  The  head  in  the  iliac  fossce  (right  or  left)  .—The  head  is  recognized 
by  its  usual  characteristics.  The  breech  is  generally  situated  in 
the  flank  or  in  the  hypochondrium  of  the  opposite  side.  According 
to  the  situation  of  the  back,  that  is  to  say  of  the  vertebral  column, 
we  have,  when  it  looks  forward  or  backward,  presentation  of  the 
thorax,  shoulder  variety,  right. or   left  (Fig.  168);  when  it  looks 


138  Sinnpiomatology  of  Pregnancy. 

upward  or  downward,  presentation  of  the  thorax,  sternal  or  dorsal 
variety.  The  diagnosis  of  the  presentation  will,  in  general,  he 
possible  by  palpation,  from  the  exact  determination  of  the  head 
and  that  of  the  hack.  Back  to  the  front,  smooth  plane.  Back  to 
the  rear,  small  parts  of  the  foetus.  Where  this  last  point  is  diffi- 
cult to  elucidate  in  a  clear  manner,  we  may  arrive  by  palpation  at 
an  exact  statement  of  the  presentation  without  being  able  to  affirm 
the  variety. 

3.  The  head  in  the  flank  (right  or  left).—  When  the  head  is  in  one  of 
the  flanks,  it  can  be  recognized  by  palpation  from  its  usual  char- 
acters. The  breech  is  found  in  the  opposite  flank  or  in  the 
neighboring  iliac  fossa. 

In  the  first  case  there  is  no  presentation,  for  the  trunk  is  distant 
from  the  opening  of  the  genital  canal  (Fig.  169).  To  constitute  a 
presentation  a  very  marked  flexion  of  the  foetus  would  be  necessary, 
so  that  the  child  will  lie  in  the  inferior  segment  of  the  uterus,  as  in 
a  hammock.  Then  we  would  have  a  presentation  of  the  abdomen 
(Fig.  170). 

In  the  second  case  (Fig.  171),  the  breech  being  in  the  iliac  fossa, 
if  its  position  is  maintained  at  the  moment  of  labor,  we  would  also 
have,  and  more  markedly  than  above,  a  presentation  of  the  ab- 
domen. But  at  this  moment  the  breech  generally  descends  into 
the  superior  strait,  then  into  the  excavation,  and  presentation  of 
the  breech  is  thus  constituted  in  place  of  that  of  the  abdomen. 

4.  The  head  is  in  the  hypochondrium  (right  or  left)  or  in  the  epi- 
gastrium.— When  the  head  is  at  the  fundus  of  the  uterus,  either  at 
the  epigastrium  or  in  one  or  the  other  hypogastrium,  the  breech  is 
found  at  the  entrance  to  the  parturient  canal,  that  is,  there  exists 
a  presentation  of  the  breech. 

The  head  most  often  occupies  the  hypochondrium  toward  which 
is  turned  the  anterior  plane,  or  the  sternum  of  the  foetus,  the  same 
as  the  breech  in  presentations  of  the  vertex. 

The  complete  breech  does  not  engage  in  the  excavation  during 
pregnancy.  This  is  not  so  with  regard  to  the  breech  in  the  incom- 
plete variety  of  the  buttocks,  that  is  found  below  the  superior 
strait  during  the  ninth  month,  and  might  be  mistaken  for  the 
vertex  in  a  rapid  examination. 

Palpation,  of  the  head  in  the  fundus  of  the  uterus,  of  the  breech 

in  the  hypogastrium  or  engaged  in  the  excavation,  and  finally,  of 

the  back,  placed  to  the  right  or  to  the  left,  permits  us  to   state 

actlythe  foetal  situation,  and  to  determine  the  presentation  as 

well  as  the  position. 

By  palpation  we  can  also  recognize  whether  the  breech  is  com- 
plete or  incomplete  variety,  the  volume  of  the  foetal  part  being  more 
siderable  in  the  first  case,  and  the  feet  being  sometimes  per- 
ceptible in  the  vicinity  of  the  head  in  the  second. 


Symptomatology  of  Pregnancy. 


189 


Palpation  also  affords  exact  information  on  the  diagnosis  of  twin 
pregnancies,  on  the  death  of  the  foetus,  and  as  to  different  patho- 
logical states. 

Borne  words  on  the  difficulties  of  palpation  and  we  shall  have 
finished  with  this  method  of  exploration.  These  difficulties  may 
be  met  at  each  one  of  the  thr<  e  portions  thai  have  been  discussed. 


Fig.  171. — Complete  breech  presentation  R  S  I  A. 

1.  Prceuterine. — Fatty  infiltration  of  the  abdominal  wall  makes 
the  sensation  obscure  in  obese  women.  Exaggerated  sensitiveness 
of  the  abdominal  wall  may  obstruct  palpation  to  such  a  point  that 
in  cases  where  precision  of  diagnosis  is  indispensable  it  is  neces- 
sary to  have  recourse  to  anaesthesia.  Uterine  anteversion  may 
render  fcetal  palpation  very  difficult.  In  this  case  the  fundus  of 
the  uterus  must  be  pushed  as  far  backward  as  possible. 

2.  Uterine. —  Tumors  of  the  uterine  wall  (multiple  fibroid.-), 
rigidity  of  this  wall  in  primiparae,  or  in  hydramnios  of  twin  preg- 
nancy, obstruct  the  hand  in  exploration  of  the  foetus.  This  may 
also  occur  from  too  frequent  contractions  of  the  uterus  during 
pregnancy  and  especially  during  labor. 

3.  Intra-wterine. — An  excess  of  the  amniotic  liquid,  twin  pregnancy 
and  death  of  the  fcetus  are  causes  of  difficulty  that  experience 
alone  can  surmount. 

4.  Auscultation. — From  experience  it  has  been  learned  that 
by  applying  the  ear  to  the  abdominal  wall  of  a  woman  toward  the 
term  of  pregnancy,  there  can  be  heard  four  varieties  ofsounds  : 


140 


Symptomatology  of  Pregnancy. 

Mother. 
y  Foetus. 


A.  A  maternal  souffle,        ... 

B.  A  foetal  double  pulsation, 

C.  Fceto-funicular  souffle, 

D.  Sounds  of  foetal  movements,  -        -  ) 

Before  beginning  the  study  of  these  sounds,  some  preliminary 
words  on  the  mode  of  practicing  obstetrical  auscultation  will  be 
useful. 

Preliminaries. — The  woman  should  be  placed  in  the  same  position 
as  for  palpation  (or  better  left  in  this  position),  since  digital  ex- 
ploration and  auscultation  generally  follow  palpation.  The  ac- 
coucheur remains  likewise  on  the  right  side  of  the  woman,  but  may 
change  sides  to  complete  his  examination. 

Auscultation  is  either  immediate  or  mediate :  Immediate,  when 
the  ear  is  directly  (or  better,  with  the  linen  or  the  chemise  inter- 
vening) applied  to  the  abdomen.  Mediate,  when  a  stethoscope  is 
interposed  between  the  ear  and  the  abdomen.  This  last  method  is 
generally  preferred,  as  less  offensive  to  the  woman's  modesty  and 
as  furnishing  clearer  and  more  exact  results. 


Figs.  174,  175. — Bell  of  obstetrical  stethoscope. 

The  choice  of  a  stethoscope  is  not  a  matter  of  indifference ;  those 
employed  for  the  thorax  are  not  so  favorable  for, obstetrical  auscul- 
tation. The  essential  condition  of  a  good  obstetrical  stethoscope  is 
that  it  shall  have  a  large  bell,  for  example,  like  that  represented  in 
Figs.  17-4  and  175.  With  these  preliminaries  we  may  proceed  to 
the  study  of  the  different  puerperal  sounds. 

A.  Maternal  souffle. — The  maternal  souffle  presents  several  im- 
portant characteristics : 

It  is  intermittent  and  synchronous  with  the  pulse  of  the  woman. 
If  the  uterus  is  auscultated  at  the  same  time  that  the  finger  explores 
the  radial  artery,  at  the  moment  the  pulse  is  felt  at  the  wrist  the 


Symptomatology  of  Pregnancy.  ill 

ear  hears  a  sound  which  occupies  a  duration  of  one-quarter,  one- 
third,  or  one-half  of  a  cardiac  revolution. 

Uterine  Contraction. 


Maternal 
Souffle. 


FlG.  176. — Evolution  of  the  maternal  souffle  during  uterine  contraction. 

Its  timbre  is  variable;  sometimes  acute,  sometimes  grave,  some- 
times musical.  It  may  be  situated  at  any  point  of  the  uterine  sur- 
face, but  is  heard  most  often  over  the  sides,  or  at  the  border  of  the 
insertion  of  the  broad  ligaments.  Its  site  is  sometimes  single, 
sometimes  double,  sometimes  multiple.  When  following  uterine 
contraction,  it  undergoes  an  augmentation  of  intensity,  then  sinks 
below  normal,  to  resume  its  first  intensity  when  the  contraction  is 
ended.     These  variations  are  put  in  schema  form  in  Fig.  176. 

This  souffle  appears  generally  at  the  beginning  of  the  second 
three  months  of  pregnancy,  augments  up  to  the  commencement  of 
the  third  three  months,  when  it  attains  its  apogee,  and  decreases 
from  this  time  (Fig.  177). 

1.  Aorto-iliac  theory  (Hans,  Bouillard). — The  souffle  is  pro- 
duced in  the  aorta  and  in  the  iliacs  compressed  by  the  uterus.  If 
tins  were  so  it  would  he  impossible  to  find  the  souffle  at  any  point 
of  the  uterine  surface,  notably  above  the  pubis  where  it  is  often  met. 

2.  Epigastric  theory  (Kiovisch,  Glenard). — These  two  authors 
have  localized  the  maternal  souffle  in  the  epigastric  arteries. 

The  objection  made  to  the  preceding  theory  applies  equally  to 
this  and  demonstrates  its  untruth.  Glenard  has,  besides,  abandoned 
his  theory,  placing  in  the  puerperal  artery  that  which  had  formerly 
been  attributed  to  the  epigastric ;  the  puerperal  artery  being  a  de- 
pendent of  the  uterus,  this  author  is  thus  ranged  in  the  uterine 
theory,  which  will  be  exposed  later. 

3.  Placental  theory  (Laennec,  Monod). — The  possibility  of  having 
two  or  three  distinct  spots  where  the  maternal  souffle  can  be  heard 
invalidates  this  theory. 

4.  Uterine  theory  (P.  Dubois). — This  is  the  generally  admitted 
theory,  localizing  in  the  vessels  of  the  uterus  the  origin  of  the  ma- 
ternal bruit  or  souffle;  thus  it  is  often  called  the  uterine  souffle. 
But,  though  in  accord  on  the  principle,  authors  differ  as  to  what 
variety  of  vessels  is  involved.  The  schema  Fig.  179  represents  the 
succession  of  uterine  vessels  showing  the  divisions,  and  the  authors 
cited  have  been  placed  opposite  the  variety  of  bloodvessels  ad- 
vanced as  a  cause. 


142 


Symptomatology  of  Pregnancy. 


A  physical  law  proves  that  a  sonorous  sound  is  produced  when  a 
fluid  circulating  in  a  tuhe  passes  from  a  narrow  region  into  an  en- 
largement ;  this  law  demonstrates  that  P.  Dubois  is  correct  in  sup- 
posing that  the  maternal  souffle  arises  at  a  moment  when  the  blood 
empties  from  the  capillaries  into  the  sinuses.  Besides,  it  is  not 
impossible  that  the  other  uterine  vessels  compressed  accidentally 
by  the  stethoscope,  by  a  tumor,  by  a  foetal  part,  or  by  any  analo- 
gous cause,  may  be  equally  the  source  of  a  maternal  bruit. 

The  maternal  souffle,  then,  takes  origin  in  any  point  of  the  uterine 
bloodvessels,  but  preferably  at  the  union  of  the  capillaries  with  the 
sinuses. 


z no  is 


^{smancjy  » 


?ua3o/['  J 


Uj 


& 


DUVN3T) 


B.  A  foetal  double  jndsation. — When  practicing  auscultation  of  the 
fcetal  heart,  the  sounds  of  which  have  been  compared  to  the  remote 
ticking  of  a  watch,  there  is  heard  (Fig.  180) : 

1.  A  first  sound,  tolerably  strong. 

2.  A  short  silence. 


Symptomatology  of  Pregnancy.  143 

3.  A  second  sound,  more  dull. 

4.  A  long  Bilence. 

The  t'a-tul  heart  beats  on  the  average  one  hundred  and  forty  times 
a  minute;  one  will  hear,  the  double  sound  in  question  one  hundred 
and  forty  times  a  minute.  The  number  <>f  pulsations  being  about 
seventy  in  the  adult,  it  will  he  seen  that  the}  are  double  this 
number  in  the  fu-tus. 

Fig    iSo.  — Foetal  heart  sounds. 

The  number  of  foetal  pulsations  may  present  quite  extensive 
variations : 


Physiological  limits     -J  ^  V 


Maximum,  160. 
mum.  120. 


,    .     .    ...    .  f  Progressive  diminution,  ioo,  90,  60,  etc.,  to  fcetal  death. 

Pathological  limits      |  Augmentation  to  190,  200,  in  cases  of  intense  fever  of  the  mother. 


Uterine  co-traction 


Fcetal  heart 
sounds. 


/ 


Fig.  181. — Evolution  of  fcetal  heart  sounds  during  uterine  contraaion. 

During  uterine  contraction,  the  frequency  is  exaggerated  moment- 
arily at  the  beginning,  then  diminishes  sometimes  to  such  a  degree 
that  the  ear  perceives  no  sound.  The  obstetrician  should  not  forget 
this  peculiarity,  which  may  lead  to  a  belief  that  the  condition  of  the 
foetus  is  serious,  when  there  is  only  a  passing  modification.  Fig. 
181,  in  schematizing  the  variations  of  the  fcetal  heart  sounds  during 
uterine  contraction,  shows  the  analogy  with  that  taking  place  in  the 
maternal  bruit. 

During  the  first  three  months  of  pregnancy,  it  has  never  been 
possible  to  hear  the  fcetal  heart  sounds.  Exceptionally  they  can 
be  perceived  during  the  fourth  month,  but  more  often  during  the 
first  half  of  the  fifth  month ;  it  is  in  general,  however,  at  about  the 
middle  of  pregnancy  that  they  become  distinctly  perceptible;  their 
clearness  progresses  to  the  end  of  gestation  as  in  the  schema,  Fig. 
18*2,  which  sums  up  what  we  have  said. 

The  perception  of  the  the  fcetal  heart  sounds  permits  us  to  affirm 
the  existence  of  pregnancy  and  that  the 'foetus  lives.  However,  this 
sign  may  be  attached  to  certain  causes  of  error ;  thus  the  maternal 
cardiac  pulsation  transmitted  to  the  abdomen  may  be  mistaken  for 


144 


Symptomatology  of  Pregnancy. 


the  foetal  heart  sounds.  To  avoid  this  confusion  it  is  sufficient  to 
explore  the  maternal  pulse  while  auscultating  the  mother;  the  syn- 
chronism indicates  the  maternal  origin  of  the  sounds.  From  this 
comes  the  very  important  precept :  Never  auscultate  the  fcetus 
without  taking  the  maternal  pulse  at  the  same  time.  In  difficult 
cases,  the  obstetrician  who  fears  a  confusion  with  the  throb  of  Ms 
own  arteries  (arteries  of  the  head,  in  particular  the  temporal)  will 
avoid  all  source  of  error  by  taking  his  own  pulse  simultaneously. 


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These  causes  of  error,  it  is  seen,  are  very  easy  to  avoid,  and  hence 
the  exellence  of  the  fcetal  heart  sounds  as  a  positive  sign  of  preg- 
nancy.  The  perception  of  these  sounds  permits,  besides,  a  watch 
over  the  life  of  the  fcetus,  and  during  labor  furnishes  the  physician 
important  knowledge  as  to  the  necessity  of  prompt  intervention 
when  a  life  is  in  danger. 

It  has  been  pretended  also  that  by  the  aid  of  auscultation  one 
could  recognize  during  pregnancy  the  sex  of  the  fcetus.  In  1859 
Frankenhauser  advanced  the  following  relation :     More  than  one 


Symptomatology  of  Pregnancy.  1  1." 

hundred  and  forty-four  pulsations  to  the  minute,  a  girl;  less 
than  one  hundred  and  forty- four  pulsations,  a  boy.  Taking  up 
this  question  again  in  1879  Danzats  modified  the  preceding  con- 
clusion. More  than  one  hundred  and  forty-four  pulsation-  to  the 
minute,  a  girl ;  less  than  one  hundred  and  thirty-five,  a  boy.  Dan- 
zats created  thus  between  one  hundred  and  forty-four  and  one  hun- 
dred and  thirty-live  pulsations  a  neutral  zone  where  diagnosis 
impossible.  From  the  researches  of  Budin  and  Chaignot,  made 
the  same  year,  it  resulted  that  these  figures  had  no  utility  in 
practice,  and  that  it  is  necessary  to  renounce  all  ideas  of  diagnosti- 
cating the  sex  of  the  child  during  pregnancy  by  auscultation  or  by 
any  of  the  other  means  proposed  to  this  end. 

Finally,  fatal  auscultation  permits  us  to  verify  the  diagnosis  of 
the  presentation  a  ml  position  made  by  palpation,  and  this  study  will 
terminate  the  subject  of  fcetal  heart  sounds.  The  sounds  of  the 
fcetal  heart  are  heard  within  a  zone  more  or  less  extended  on  the 
abdominal  wall,  a  zone  which  represents  a  circle  of  ten  to  fifteen 
centimetres  diameter.  In  proportion  as  the  ear  or  stetlioscoi*  :- 
approached  to  the  center  of  tins  circle,  the  sound  becomes  clearer 
and  stronger.  This  region,  where  the  heart  sounds  are  particularly 
clear,  is  called  the  focus  of  auscultation.  This  focus  is  usually  single  ; 
however,  as  will  be  seen  later  in  a  simple  pregnancy,  it  may  lie 
double,  as  in  the  case  of  twins.  The  foci  of  auscultation  will  vary 
with  the  situation  of  the  fcetal  heart ;  that  is,  each  presentation  and 
position  will  have  its  special  focus.  Let  us  study  these  different 
foci  by  commencing  with  the  presentation  of  the  cephalic  ovoid. 

1.  Vertex. — I  will  suppose  the  vertex  engaged  in  the  excavation 
(we  will  see  later  that  the  height  of  the  focus  of  auscultation  varies 
with  the  degree  of  engagement).  I  use  as  a  diagram  a  series  of 
lines  which  take  the  umbilicus  as  a  starting  point  and  dispose 
themselves  in  a  fan  shape  to  the  different  points  of  the  pelvis,  as 
follows  (id.  both  sides) : 

Antero-superior  iliac  spine.         Superior  ilio-umbilical  line. 
Anteroinferior  iliac  spine.  Inferior  ilio-umbilical  line. 

Ilio-pectineal  eminence.  '  Umhilico-pectineal  line. 

Pubic  spine.  Umbilico-pubic  line. 

Total:  eight  lines. 

It  is  on  the  paths  of  these  eight  lines  that  we  find  the  foci  of 
auscultation  of  the  eight  positions  of  the  vertex. 

Schema  183  represents  the  site  of  the  different  foci  of  auscultation 
at  the  point  where  each  one  interrupts  a  line ;  the  name  of  the 
position  is  given  at  the  side. 

It  will  be  remarked  that  for  LOP  there  exists  two  foci.     This 
the  only  position  where  this  peculiarity  exists.     The  line  on  which 
is  seated  the  left  focus  is  found  above  the  left  superior  ilio-umbilical 
(supplementary  line).     In  proportion  as  the  back  of  the  foetus  turns 


146 


Symptomatology  of  Pregnancy. 


posteriorly  the  right  focus  becomes  more  and  more  clear,  and,  on 
the  contrary,  it  is  that  of  the  left  that  becomes  louder  when  the 
back  is  directed  forward,  approaching  LOT. 

To  reconstruct  tliis  schema  from  memory  it  is  sufficient  to  recall  that 
the  focus  of  L  0  A  (the  line  of  which  is  expressly  accentuated)  is 
found  on  the  left  inferior  ilio-umbilical  line. 


Fig.  183. — Vertex.     Foci  of  Auscultation.     Stethoscopic  Fan. 


Foetal Part 

Superior Strait 

2 

EXCA V ATI  ON 

3 

Medir/v. Strait 

VUL+t++*mtHHtVA 


Fig.  184. — Height  of  foci  of  Ausculation  varying  according  to  the  degree  cf 
engagement  of  the  fcetal  part.  (The  inferior  lines  indicate  the  height  of  the  fcetal 
part  which  presents  and  the  superior  analogous  lines  the  height  of  the  foci  of  auscul- 
tation which  corresponds  to  them.) 

What  has  been  said  applies  to  cases  where  the  vertex  is  engaged 
in  the  excavation.  But  what  is  the  site  of  the  different  foci  when 
engagement  has  not  taken  place  or  when,  on  the  contrary,  the  head 


Symptomatology  of  Pregnancy. 


117 


has  arrived  at  the  vulva  ?  Fig.  18  i  responds  to  this  question  ;  it  is 
destined  to  show  the  relative  height  of  the  foci  of  auscultation,  fol- 
lowing the  degree  of  engagement  of  the  foetal  part;  the  upper  black 
line  corresponds  to  the  foetal  part  free. 

These  different  heights  being  known  it  is  sufficient  to  return  to 
Fig.  L88  and  transport,  parallel  to  itself,  each  of  the  foci,  either  up- 
ward or  downward,  according  to  the  degree  of  engagement;  thus 
we  will  have  the  successive  positions  occupied  by  the  foci  during 
the  successive  descent  of  the  head. 

Examples  :  In  L  0  T,  head  mobile  above  the  superior  strait,  the 
focus  will  be  in  A. 

In  0  S,  head  fixed  at  superior  strait,  the  focus  will  be  in  B. 

In  0  P,  head  at  the  vulva,  the  focus  will  be  in  C  (Fig.  185). 


Fig.  185. — Vertex.     Variations  in  the  height  of  f<  cus  of  auscultation 
according  to  the  degree  of  engagement  ot  the  fcelal  part. 

2.  Face. — I  proceed  likewise  for  the  determination  of  the  foci  in 
the  positions  of  the  presentation  of  the  face,  supposing  that  labor 
is  advanced  so  that  the  fcetal  part  is  in  the  excavation.  The  stetho- 
scopic  fan  is  given  in  Fig.  186.  The  mnemotechnic  mark  here  is 
the  L  M  A  line,  the  same  as  L  0  A  for  the  vertex.  The  E  M  P  is 
here  analogous  to  L  0  P  as  to  a  double  focus,  for  the  cardiac  region 
of  the  foetus  is  equally  distant,  right  and  left,  from  the  abdominal 
wall.  Although  this  double  focus  has  not  been  described,  it  is 
probable  that  it  exists  and  for  my  part  I  have  been  able  to  recognize 
it  in  a  similar  case.  With  regard  to  the  height  of  these  different 
foci,  according  to  the  degree  of  engagement,  I  return  to  what  has 
been  said  of  the  vertex.  Fig.  184  applies  as  well  to  presentations 
of  the  face  as  to  those  of  the  vertex. 

3.  Forehead. — The  different  foci  of  auscultation  in  presentation 
of  the  forehead  are  not  sufficiently  known  to  allow  me  to  touch 


148 


Symptomatology  of  Pregnancy. 


upon  their  description.  They  demand  new  study.  Each  presen- 
tation of  the  forehead  being  intermediate  between  a  presentation  of 
the  vertex  and  of  the  face,  one  can  take  a  point  situated  on  the 
middle  of  a  line  reuniting  the  two  foci  of  corresponding  presentations 
and  approximately  fix  the  site  of  the  one  sought. 


A%t. 


Fig.  i  86  — Face.     Foci  of  auscultation,     ;5tethoscopic  fan. 

4.  Breech. — I  suppose  the  breech  engaged  in  the  excavation,  the 
foci  are  disposed  in  a  fan  (Fig.  187)  analogous  to  those  of  the  face 
and  vertex.  For  Pi  S  P  I  have  marked  two  foci  of  auscultation 
which  exist  probably  as  in  L  0  P  or  Pi  M  P,  but  this  fact  has  not 
been  verified.  The  line  L  S  A  is  that  from  which  the  fan  can  be 
reconstructed  from  memory.  With  regard  to  the  height  of  the  foci, 
I  will  repeat  that  which  has  been  given  for  the  vertex  and  face,  for 
since  the  researches  of  M.  Eibemont,  it  has  been  shown  that  in  a 
foetus  doubled  on  itself,  as  it  is  in  the  uterine  cavity,  the  heart  is 
equally  distant  from  the  vertex  and  from  the  breech ;  the  height  of 
the  focus  of  auscultation  will  be  the  same  for  the  vertex  and  for  the 
breech  with  equal  degrees  of  engagement.  Presentation  of  the 
breech  being  very  rarely  accompanied  by  engagement  during  preg- 
nancy, it  will  be  understood  that  the  foci  of  auscultation  will  be 
found  in  parallel  circumstances  above  the  umbilicus. 

5.  Thorax. —  Shoulder  presentations,  other  than  the  varieties  of 
the  right  or  left  shoulder,  being  rare,  we  have  only  at  present  de- 
termined the  foci  for  these  two  varieties,  and  in  their  two  most 
usual  positions,  that  is,  the  right  and  the  left  acromio-iliac  trans- 
verse, B  A  T  and  L  AT. 

('..  Abdomen. — The  great  rarity  of  these  presentations  has  not  yet 
permitted  us  to  determine  the  foci  of  auscultation. 

Ii . •  - i <  1  o -  tin-  engagement  of  the  fVetal  part,  there  are  other  causes 
which  may  produce  variation  in  the  situation  of  the  foci  of  auscul- 
tation, such  as  lateral  inclination  of  the  uterus,  or,  again,  anterior 


Symptomatology  of  Pregnancy. 


1  c.i 


inclination,  which,  for  example,  notably  lowers  the  focus  in  L  0  T, 
when  it  is  pronounced.     All  these  variations  are  complications,  bul 

tin-  physician  should  never  forget  their  possibility,  in  order  i<>  k<  ep 
in  mind  certain  apparent  anomalies,  the  details  of  which  are  too 
extended  to  produce  here.  The  knowledge  of  the  preceding  foci  as 
described  is  not  sufficient  alone  for  diagnosis  of  presentation  and 
position,  but  it  permits  us,  diagnosis  being  firsi  made  by  palpation, 
to  obtain  verifications  by  the  aid  of  the  ear,  and  enables  the 
assurance  that  the  focus  is  placed  in  the  situation  indie  at  i  d  for  the 
supposed  presentation  and  position.  A  focus  placed  in  another 
region  puts  one  on  the  track  of  an  error  committed  and  leads  to  the 
necessary  rectification. 


**'*• 


Fig.  1S7. — Breech.     Foci  of  auscultation.     Stethoscopic  fr.n. 

C.  Fceto-funicular  sovffle. — At  the  same  time  with  the  fcetal  heart 
sounds,  there  is  sometimes  beard  a  blowing  sound,  usually  single, 
exceptionally  double.  This  souffle  differs  essentially  from  that 
previously  studied  (maternal  souffle),  and  is  easily  distinguished 
from  it,  for  tbe  first  is  synchronous  with  the  pulsations  of  the 
mother,  tbe  second,  with  tbe  fcetal  pulsations. 

The  fceto-funicular  souffle  recognizes,  as  its  name  indicates,  a 
double  origin:  Either  the  foetus,  cardiac  (heart)  souffle:  or  the 
cord,  funicular  (vessels)  souffle.  The  cardiac  souffle  of  the  foetus  is 
due  either  to  a  lesion  of  tbe  valvular  orifices,  as  in  adults  ;  to  an  in- 
sufficient permeability  of  the  foramen  ovale;  or,  with  a  normal 
heart,  to  modifications  in  the  blood,  producing  sounds  analogous  to 
those  which  are  designated  under  the  name  anaemic  in  the  adult, 
and  the  pathology  of  which  is  still  unknown. 

The  funicular  souffle,  exceptionally  caused  by  the  semilunar  folds 
which  exist  in  tbe  umbilical  vessels,  is  generally  due  to  compression 
of  tbe  cord,  either  between  the  back  of  tbe  child  and  the  uterine 
wall,  or  by  circular  constrictions.  Cbarrier,  in  making  of  this 
souffle  a  sure  sign  of  circular  constriction  of  tbe  cord,  has  heen 


150  Symptomatology  of  Pregnancy. 

much  too  positive,  and  is  unwise  in  proposing  premature  artificial 
labor  in' such  cases  to  save  the  life  of  the  child. 

We  do  not  possess  exact  and  sufficient  symptoms  to  enable  us  to 
recognize  the  different  varieties  of  fcetal  cardiac  souffle,  so  that  all 
the  ambition  of  the  obstetrician  should  be  confined  to  distinguishing 
a  foetal  souffle  from  a  funicular  souffle,  and  yet  this  diagnosis 
is  not  always  possible.  The  cardiac  souffle  has  its  maximum  of 
intensity  at  the  focus  of  auscultation  of  the  fcetal  heart,  and,  on 
the  contrary,  the  funicular  souffle  has  its  maximum  of  intensity 
situated  at  a  different  point,  in  the  region  of  the  cord.  This  sign  is 
that  which  will  better  permit  the  differentiation ;  those  distinctions 
which  are  based  on  the  intensity  or  the  variability  of  the  murmur 
furnish  only  an  incomplete  security.  The  fceto-funicular  souffle 
has,  in  the  point  of  view  of  the  existence  of  pregnancy,  the  same 
semeiological  value  as  the  fcetal  heart  sounds — it  indicates  the 
presence  of  a  living  foetus,  but  its  importance  is  very  small  com- 
pared with  the  existence  of  the  fcetal  heart  sounds,  so  clear  and 
easy  to  find. 

D.  Sounds  of  fatal  movements. — In  practicing  auscultation  during 
a  certain  time  there  is  perceived  sometimes  a  rustling,  analogous  to 
that  produced  by  the  two  hands  applied  on  the  ear  when  a  slight 
movement  is  given  to  the  outer  one.  Sometimes  a  shock  is  heard, 
sudden  and  dull,  like  that  obtained  when  striking  with  one  finger  on 
the  hand  covering  as  before  the  pavilion  of  the  ear.  Occasionally 
these  shocks  take  a  peculiar  regularity,  as  if  the  foetus  pulsated 
slowly  in  the  interior  of  the  ovular  cavity  (rhythmic  movements).  The 
rustlings  are  due  to  the  displacements  of  the  foetus  in  totality ;  the 
shocks,  to  movements  of  small  fcetal  parts  which  strike  the  uterine 
wall ;  the  cause  of  the  rhythmic  movements  is  ignored,  besides  they 
have  no  special  semeiological  value.  The  sounds  of  foetal  movements 
commence  with  the  movements  themselves,  that  is,  at  the  beginning 
of  the  fourth  month  of  pregnancy,  but  they  are  not  clearly  per- 
ceptible until  about  the  middle  of  the  fourth  month.  Like  the 
foetal  heart  sounds,  they  constitute  a  positive  sign  of  the  existence 
and  the  life  of  the  foetus.  However,  it  is  important  not  to  confuse 
them  with  intestinal  sounds,  nor  with  the  shocks  which  abdominal 
muscular  contractions  may  give  to  the  stethoscope.  These  causes 
of  error  can  only  be  avoided  in  the  second  half  of  pregnancy,  when 
the  perception  of  the  foetal  shock  had  become  clear  and  distinct ; 
but  at  this  time  this  symptom,  which  would  be  important  if  unique, 
generally  loses  its  advantages  by  the  appearance  of  other  signs  of 
pregnancy  more  easily  appreciated. 

5.  Digital  examinaiton.  —The  uterus  is  directly  accessible  by 
the  vagina,  indirectly  by  the  rectum  and  bladder,  in  such  a  way 


Symptomatology  of  Pregnancy. 


151 


that  the  finger  penetrating  into  these  different  cavities  may  famish 
valuable  information  on  the  gestating  organ  and  its  contei  I 
exploration  is  dependent  upon  the  -<  use  of  touch.     It  U  then  only  a 

variety  of  palpation.  One  is  internal,  the  other  is  external.  In 
these  internal  explorations  the  fingers  are  in  contact  with  the 
mucous  membrane,  in  palpation  they  are  in  contact  with  the 
integument. 

Digital  examination  can  be  made  : 

1.  By  the  urethra  and  bladder — vesical  touch. 

2.  By  the  anus  and  rectum — rectal  touch. 

3.  By  the  vulva  and  the  vagina— vaginal  touch. 

I  shall  be  brief  as  to  the  first  two  and  shall  dwell,  on  the  con- 
trary, on  the  last. 

1.  Vesical  touch  requires  a  previous  dilatation  of  the  urethra,  an 
operation  which  prevents  its  use  in  pregnancy. 

2.  Rectal  touch,  practiced  after  a  previous  evacuation  of  fecal 
materials,  gives  information  on  the  volume  of  the  uterus,  on  the1 
exact  situation  of  tumors  placed  behind  it  and  on  some  other  points 
of  secondary  importance.  It  should  be  resorted  to  when  vaginal 
examination  is  difficult  or  impossible  on  account  of  some  obstacle, 
such  as  vaginismus,  retraction  or  cicatricial  obliteration  of  the 
vagina,  intact  or  too  narrow  hymen.  But  the^e  conditions  are  ex- 
ceptions and  in  the  great  majority  of  cases  vaginal  touch  will  be 
used. 


Fig    iSq  — Dorsal  position. 

3.  Vaginal  touch  may  be  performed  with  the  woman  in  the  upright 
position  or  lying  dowm.  The  upright  position  permits  a  rapid  and 
summary  examination,  but  very  incomplete.  The  horizontal  position 
is  the  only  one  which  allows  a  conscientious  and  satisfactory  exami- 
nation and,  except  in  rare  cases,  it  should  always  be  used. 

The  woman  should  be  placed  in  the  same  position  as  for  pal- 
pation, or  rather  left  in  this  position,  since  one  generally  practices 
digital  examination  after  palpation  and  auscultation,  there  is  simply 
ne<  ded  a  slightly  more  marked  separation  of  the  thighs  (with  slight 
flexion  and  the  elevation  of  the  buttocks  with  the  aid  of  a  cushion 
dorsal  position)  (Fig.  189).  Such  is  the  French  position.  In  Eng- 
land the  woman  is  placed  on  the  left  side,  the  thighs  flexed  at  a 
right  angle  on  the  trunk,  the  upper  one  a   little  more  than  the 


152 


Symptomatology  of  Pregnancy, 


lower  (lateral  position)  (Fig.  190).  Exceptionally,  and  in  certain 
pathological  conditions,  the  woman  is  placed  on  the  knees  and 
elbows  (genu-pectoral position)  (Fig.  191). 


Fig.  190. — Lateral  position. 

Let  us  suppose  the  woman  in  the  dorsal  position  and  proceed  to 
digital  examination.  Exploration  may  be  made  with  either  hand, 
by  preference  with  the  right,  the  most  used ;  in  this  case  the  phy- 
sician places  himself  at  the  woman's  right.  It  is  important  for 
tins  to  place  the  woman  in  her  bed  so  that  her  right  side  is  easily 
accessible. 


Fig.  191. — Genu-pectoral  position. 

Digital  examination  or  touch  may  be  : 

Unidigital:  practiced  with  the  index  finger,  the  other  fingers 
being  flexed  and  folded  in  the  hollow  of  the  hand  (Fig.  192). 

Bidigitcd:  index  and  middle  finger  (Fig.  193).  The  introduction 
of  two  fingers  gives  greater  length,  the  middle  finger  permitting 
deeper  penetration,  and  may  be  used  in  muciparous  women  with- 
out inconvenience.  In  a  primiparous  women  this  simultaneous 
introduction  is  often  painful  and  should  be  avoided. 

Man  mil .  the  whole  hand  can  be  made  to  penetrate  into  the  geni- 
tal organs,  usually  to  explore  the  contents  of  the  uterus,  in  case  of 
vicious  presentation  for  example.  The  hand,  disposed  as  in  Fig. 
194,  can  scarcely  ever  be  introduced  without  anaesthesia. 

While  one  hand  practices  vaginal  touch,  the  other  should  always 


Symptomatology  of  Pregnancy. 


153 


be  placed  on  the  abdomen,  combining  and  completing  the  explo- 
ration. The  finger  that  is  introduced  into  the  genital  organs  should 
be  aseptic  and  covered  with  an  oily  Bubstance  to  permit  an  easy 
gliding  (vaseline,  oil,  cold  cream,  cerate,  etc.). 


Fig.  192. — Unidigital  touch.      Fig.  193. — Bidigital  touch.      Fig.  194. — Manual  touch. 

Vaginal  touch  is  executed,  like  palpation,  by  a  series  of  examin- 
ations : 

1.  Vulvar. 

2.  Vaginal. 

3.  Uterine. 

4.  Periuterine. 

5.  Pelvic. 

The  pelvic  exploration  is  only  a  variety  of  the  periuterine,  but  I 
separate  them  for  the  clearness  of  description. 

We  shall  study  first  digital  examination  on  the  non-pregnant 
woman,  to  note  the  changes  caused  progressively  by  the  develop- 
ment of  the  ovum. 


A.   Vaginal  touch  in  the   non-pregnant  woman. — 1. 

Vulvar. — The  vulva  being  easily  accessible  to  vision,  the  obstetrician 
will  derive  more  information  from  exploration  of  the  region  by  the 
eye  than  by  the  finger.  There  are  two  orifices  that  it  is  necessary 
to  become  familiar  with  by  touch,  the  urethral  for  catheterism  and 
the  vaginal  which  conducts  the  finger  toward  the  cervix.  Explo- 
ration is  commenced  by  search  for  the  vaginal  orifice.  For  this  the 
finger  will  be  held  vertically,  direct  along  the  inner  surface  of  the 


154  Symptomatology  of  Pregnancy. 

thigh,  until  in  contact  with  the  vulvo-perinseal  region  where  the 
vulvar  opening  is  detected.  At  this  moment  the  finger  is  generally 
in  contact  with  the  perinseum  and  by  ascending  a  little  the  vaginal 
orifice  is  reached.  To  determine  the  situation  of  the  urethral 
orifice,  the  finger,  after  having  found  the  vaginal  orifice,  explores 
the  vestibule  from  below  upward  and  meets  a  small  opening,  which 
with  a  little  experience  can  be  easily  recognized. 

2.  Vaginal. — The  finger  in  passing  through  the  vagina  passes 
successively  the  vulvo-vaginal  orifice  and  the  muscular  ring  con- 
stituted by  the  coccy-perimeal  levator.  Continuing  on  its  way  the 
finger  following,  sometimes  the  anterior  wall,  sometimes  the  pos- 
terior wall,  sometimes  the  right  or  left  lateral  wall,  arrives  in  the 
corresponding  culs-de-sac  which  surround  the  cervix.  I  only  note 
in  passing  the  importance  of  seeking  carefully  for  double  vaginas, 
which  often  pass  unnoticed. 

3.  Uterine. — To  attain  the  cervix  in  difficult  cases,  it  is  necessary, 
the  buttocks  of  the  patient  being  elevated : 

a.  To  depress  the  elbow  to  the  plane  of  the  bed,  thus  giving  the 
finger  a  proper  direction. 

b.  To  separate  successively  the  labia  majora  and  minora  of  each 
side,  in  such  a  way  as  to  insinuate  the  hand  between  them ;  by  this 
manoeuvre  one  can  easily  penetrate  a  finger's  breadth  farther. 

"When  the  cervix  is  examined,  the  anterior,  lateral  and  posterior 
surface  of  the  uterus  can  be  explored,  by  successively  depressing 
each  cul-de-sac,  while  the  abdominal  hand  affords  a  support  from 
above  downward  in  an  umbilico-coccygeal  direction. 

4.  Periuterine. — By  depressing  the  vaginal  wall,  circularly  from 
the  posterior  to  the  anterior  cul-de-sac,  the  finger  meets  : 

The  rectum.  • 

The  ovary  ") 

The  tube  >•  Broad  ligament. 

The  round  ligament  J 

The  bladder,  ureter,  urethra. 

The  exploration  of  the  ovary,  of  the  tube,  and  especially  of  the 
round  ligament  and  the  ureter  demands  great  experience,  and  some- 
times the  most  experienced  finger  can  not  perceive  them.  The 
direction  in  which  the  finger  leaving  the  uterus  will  meet  the  dif- 
ferent organs  is  indicated  by  Fig.  195.  These  different  organs  are 
more  easily  found  when  they  become  the  seat  of  a  pathological 
change  and  it  is  also  in  such  circumstances  that  their  exploration 
becomes  useful. 

5.  Pelvic. — By  strongly  depressing  the  vagina  and  the  contiguous 
sofl  tissues,  one  can,  without  actual  pain  to  the  woman,  explore  the 
pelvic  will  and  even  arrive  at  the  superior  strait  and  at  the  sacro- 
vertebral  angle.  The  great  importance  of  this  examination  will  be 
comprehended  in  the  study  of  the  pathological  pelvis. 


Symptomatology  of  Pregnancy. 

ill. i'M    i  und  nr;thr... 


155 


•    Round  ligament. 


•Tube. 


>.  s  Ovary. 

„  Rectum. 
Fig.  195.  —  Periuterine  touch. 

B.  Vaginal  touch  during1  pregnancy. — We  shall  follow  the 
different  steps  indicated  above,  noting  the  modifications  caused  by 
conception. 

1.  Vidvular. — There  is  no  important  change  outside  the  hypertro- 
phy of  its  elements. 

k2.  Vaginal. — I  simply  recall  the  circular  fold  which  is  sometimes 
formed  at  an  advanced  period  of  pregnancy.  The  finger  often 
finds  small  projections  in  the  vaginal  wall,  a  little  larger  than  the 
head  of  a  pin.  These  are  the  result  of  granular  vaginitis,  a  frequent 
affection  of  pregnancy,  manifested  as  a  blennorrhagic  vaginitis  by  a 
yellowish  leucorrhcea,  but  absolutely  distinct  with  regard  to. its 
nature  and  it  is  not  venereal,  although  it  relates  to  microbes. 
•  3  Uterine. — At  an  advanced  period  of  pregnancy,  when  the  cervix 
is  completely  softened  and  its  consistency  identical  with  that  of  the 
vagina,  even  a  practiced  finger  may  meet  actual  difficulty  in  cervical 
exploration.  To  find  the  cervix  in  difficult  cases  it  is  necessary  to 
follow  the  vaginal  fundus  in  different  directions ;  in  this  series  of 
successive  explorations  the  finger  will  meet  the  organ  and  recognize 
its  orifice. 

The  finger  permits  us  to  verify  the  modifications  of  the  cervix  and 
of  the  body  of  the  uterus  (hypertrophy  and  softening).  The  soften- 
ing of  the  cervix  and  the  augmentation  of  the  volume  of  the  body 
of  the  uterus  are,  at  the  beginning  of  pregnancy  in  the  absence  of 
positive  symptoms  which  do  not  exist  at  this  period,  valuable 
indices  for  diagnosis. 

Toward  the  middle  of  pregnancy  appears  the  ballottement,  called 
vaginal  in  distinction  from  abdominal.  When  the  finger  placed  in 
the  cervix,  or  in  one  of  the  culs-de-sac  (preferably  in  the  anterior), 
impresses  a  slight  push  from  below  upward,  it  has  the  sensation  of 


156  Symptomatology  of  Pregnancy. 

a  hard  bod}'  which  retreats  and,  at  the  end  of  some  seconds,  strikes 
upon  the  finger  in  resuming  its  first  position.  This  sensation  of 
retreat  and  return  is  balottement.  It  is  generally  produced  by  the 
head  of  the  foetus,  exceptionally  by  the  breech,  sometimes  by 
another  foetal  part.  Very  exceptionally  ballottement  may  be  per- 
ceived at  the  beginning  of  the  second  three  months  of  pregnancy. 
In  general  it  is  only  felt  after  four  months  and  a  half,  and  it 
becomes  especially  clear  during  the  seventh  month;  during  the 
ninth  month  it  is  met  no  longer  unless  there  is  hydramnios,  for  the 
foetus  becomes  too  heavy  and  too  closely  surrounded  to  retreat 
before  the  pressure  of  the  finger  (Fig.  196). 

Vaginal  ballottement. 


I 

Nul.»  • 


Fig.  196. — Vaginal  ballottement. 

Is  vaginal  ballottement  a  positive  sign  of  pregnancy  ?  An  analo- 
gous ballottement  may  be  produced  by  a  large  vesical  calculus,  or 
by  the  body  of  the  uterus  in  anteflection  and  very  mobile  on  the 
cervix,  or  again  by  some  periuterine  tumor.  Like  all  other  positive 
signs,  vaginal  ballottement  has  then  its  sources  of  error,  but  these 
are  avoided  if,  as  in  abdominal,  all  ballottement  is  eliminated  that 
is  not  produced  by  an  intra-uterine  tumor.  Vaginal  ballottement 
produced  by  an  intra-uterine  body  is,  then,  a  positive  sign  of 
pregnancy.  By  this  restriction  the  above-mentioned  sources  of 
error  will  be  avoided,  i.  e.,  those  belonging  to  periuterine  or  uterine 
tumors,  for  none  of  them  are  intra-uterine. 

But  it  is  asked,  How  may  we  be  assured  that  the  tumor  is  intra- 
uterine "?  This  is  decided  by  attentive  exploration  of  the  inferior 
segment  of  the  uterus,  and  in  doubtful  cases,  by  waiting  a  con- 
traction by  which  we  may  be  assured  that  the  tumor  explored  is 
contained  in  the  uterus.  There  may  be  doubtful  cases  where  the 
obstetrician  may  be  unable  to  decide,  but  this  is  no  reason  for 
eliminating  ballottement  from  the  positive  signs,  for  with  such 
reasoning  there  would  remain  no  positive  signs,  not  even  the  sounds 
of  the  fcetal  heart,  which  are  sometimes  too  vague  to  be  affirmative. 

Digital  examination  also  permits,  at  a  sufficiently  advanced  period 
of  pregnancy,  recognition  of  the  characters  of  the  foetal  part  which 
presents.  When  this  relates  to  the  vertex  there  is  a  smooth,  even, 
hard  tumor,  usually  engaged  in  the  excavation.  When  there  is 
presentation  of  the  brow,  the  tumor  is  also  smooth  but  not  engaged. 
In  a  face  presentation,  the  tumor  is  somewhat  unequal,  with  a 


Symptomatology  of  Pregnancy.  l.~< 

smooth  forehead  and  regular  at  the  Bide.  There  is  no  engagement 
ivciy  exceptional  during  pregnancy).  The  breech  La  recognized  by 
tumor,  less  bard  than  the  head  and  less  equal,  accompanied  by 
small  parts  and  not  engaged  when  the  breech  is  complete,  often 
engaged  on  the  contrary,  when  it  is  incomplete.  With  a  presen- 
tation of  the  thorax  or  abdomen  the  fetal  partis  usually  inaccessible 
during  pregnancy. 

In  many  cases  the  details  of  the  foetal  presentation  can  be  felt 
through  the  uterine  segment  and  to  this  I  shall  return  apropos  of 
examination  during  labor,  when  the  cervix  is  open.  In  some  cases 
of  great  permability  of  the  cervix,  the  exploring  finger  arrives  at  a 
foetal  part  simply  covered  by  the  membranes,  and  clearly  recognizes 
the  presence  of  a  child  by  noting  a  hand,  a  foot,  an  osseous  suture, 
a  fontanelle  or  the  ocular  globe.  The  clear  perception  of  a  fcetal 
part  by  vaginal  touch  is  a  positive  sign  of  pregnancy,  but  it  is  of 
service  only  in  relatively  rare  cases. 

4,  .">.  Periuterine  mid  pelvic. — The  bladder  and  the  uterus  may  also 
be  explored  by  the  finger  during  pregnancy,  although  the  bladder 
often  ascends  above  the  pubes.  With  regard  to  the  broad  liga- 
ments and  the  organs  they  contain,  their  ascension  with  the  uterus 
renders  them  inaccessible  to  vaginal  examination.  I  only  mention 
the  examination  of  the  pelvis,  in  which  pregnancy  causes  no  modi- 
fication perceptible  to  touch  in  the  normal  state.  (The  pathological 
modifications  will  be  stated  under  puerperal  pathology.) 


158  The  Diagnosis  ot  Pregnancy. 


CHAPTER  VII. 


THE   DIAGNOSIS   OF   PREGNANCY. 

The  various  signs  or 'pregnancy  which  we  shall  now  study  in  detail 
are  divided  into  two  categories : 

1.  The  first,  dependent  on  the  mother,  are  called  probable  or  pre- 
sumptive signs,  for  if  they  afford  a  suspicion  of  pregnancy  and 
render  it  probable,  they  do  not  authorize  its  affirmation. 

2.  The  second,  dependent  on  the  foetus,  are  termed  positive  signs, 
for  then  presence  places  pregnancy  beyond  doubt. 

I  shall  only  recall  these  various  signs,  as  we  are  now  familiar  with 
them  and  as  their  value  has  been  discussed  in  describing  them. 

A.  Probable  or  maternal  signs. 

1.  Genital  system  and  vicinity. 

Uterus. — Suppression  of  the  menses. 

Progressive  increase  in  size. 

Special  softness  of  the  body  and  of  the  cervix. 

Intermittent  contractions. 

Existence  of  the  maternal  souffle. 
Vagina. — Vaginal  pulse. 

Violaceous  coloration. 
Vulva. — Hypertrophy. 

Violaceous  coloration. 
Abdominal  wall. — Increase  in  size  of  the  abdomen. 

Linaer  albicantes. 

Pigmentation  along  the  linea  alba. 

Umbilicus  :  Depression,  then  flattening,  sometimes 
projections. 
Breasts. — Increase  in  size. 

Projection  and  exaggerated  sensitiveness  of  nipples. 

Flow  of  colostrum. 

Hypertrophy  of  Montgomery's  tubercules. 

Pigmentation  of  the  areolse,  and  formation  of  the 
secondary  areola. 

Linear  albicantes. 

2.  Nervous  system. 

Modifications  of  the  senses  of  the  intellect  and  of 
the  will  (abnormal  desires). 

3.  Respiratory  system. 

Dyspnoea. 

Modification  of  the  quantity  of  carbonic  acid  exhaled. 


The  Diagnosis  of  Pregnancy.  159 

4.  Circulatory  system. 

Globular  anamia  and  serous  plethora. 
•    Cardiac  hypertrophy. 

Peripheral  venous  dilatation  (varices). 
•    5.  Urinary  system. 

Diminution  of  the  solid  elements  of  the  urine. 
Frequency  of  albuminuria  and  of  glycosuria. 
Frequency  of  disturbances  of  micturition. 

6.  Cutaneous  system. 

Pigmentary  collections. 

7.  Digestive  system. 

Modifications  of  the  appetite. 

Vomiting. 

Retardation  of  the  different  nutritive  processes ;  ab- 
sorption, assimilation,  disassimilation,  elimi- 
nation, with  different  diseases  resulting. 

B.  Positive  or  foetal  signs  (Six). 
Two  obtained  by  palpation. 

1.  Passive  movements  or  abdominal  ballottement. 

2.  Active  movements. 
Two  by  auscultation. 

3.  Fcetal  heart  sounds  (or  fceto-funicular  souffle). 

4.  Fcetal  movements. 
Two  by  digital  examination. 

5.  Passive  movements  or  vaginal  ballottement. 

6.  Detection  of  a  foetal  part. 

I  recall  that  these  positive  signs  to  be  actually  considered  as  such 
must  unite  certain  indispensable  conditions,  which  are: 

1.  Clearness. — When  our  sensations  are  not  sufficiently  exact,  con- 
clusions should  be  suspended. 

2.  Certain  peculiarities. 

a.  For  abdominal  ballottement. — The  tumor  which  gives  the  sen- 
sation of  ballottement  must  be  intra-uterine. 

J).  For  the  active  movement  perceived  by  palpation. — There  must  be 
no  interposition  of  intestine  between  the  uterus  and  the  abdominal 
wall. 

c.  For  the  foetal  heart  sounds. — There  must  be  no  synchronism  with 
the  maternal  pulse 

d.  For  audition  of  the  foetal  movements. — The  woman  must  be 
absolutely  quiet  and  contract  no  muscle  of  the  abdominal  wall. 

e.  For  vaginal  ballottement. — The  tumor  affording  ballottement 
must  be  intra-uterine. 

/.  For  detection  of  a  fcetal  part. — The  fcetal  part  explored  must 
exactly  recall  a  region  of  the  child  easily  appreciated. 


160  The  Diagnosis  of  Pregnancy. 

With  these  signs  in  view  let  us  examine  the  possibilities  of  the 
diagnosis  of  pregnancy  at  different  periods  in  its  development.  I 
shall  especially  have  in  mind  normal  (physiological)  pregnancy,  and 
shall  close  with  some  considerations  on  the  difficulties  that  different 
pathological  states  may  surround  the  diagnosis 

A.  Normal  pregnancy. — Pregnancy  lasts  nine  months,  which 
may  be  divided  into  three  parts,  and  the  diagnosis  varies  according 
as  we  have  to  consider  the  first,  the  second,  or  the  third  three 
months. 

First  three  months. — During  this  time  no  positive  sign  appears 
and  we  are  then  forced  to  hold  to  probable  signs.  Among  these 
there  are  three  especially  which  should,  on  account  of  their  relative 
importance,  fix  the  attention  of  the  obstetrician  and  which  are  like 
a  diagnostic  tripod  at  this  period,  the  other  signs  only  constituting 
adjuvants.     These  are : 

1.  The  modifications  of  the  breasts  (development  of  the  gland,  of 
the  tubercles  of  Montgomery,  pigmentation  of  the  areola,  presence 
of  colostrum.) 

2.  The  cessation  of  the  menses. 

3.  The  increase  in  volume  and  the  softening  of  the  uterus. 

If  we  are  consulted  by  a  woman:  (1)  who  can  afford  exact  infor- 
mation on  the  modifications  of  the  breasts ;  (2)  whose  menstruation, 
habitually  regular,  has  been  suddenly  arrested  without  appreciable 
pathological  cause,  and  (3)  finally,  when  palpation  permits  us  to 
state  clearly  the  increase  in  size  and  the  softening  of  the  uterus, 
we  can  be  almost  sure  of  the  existence  of  pregnancy. 

The  association  of  these  three  signs  of  probability  is  almost 
equivalent  to  a  positive  sign;  I  say  almost,  for  the  existence  of 
pregnancy  should  never  be  affirmed  before  meeting  one  or  more  of 
the  positive  signs. 

The  other  probable  signs  may  be  grouped  around  the  preceding 
three  and  by  their  number  and  clearness  may  diminish  the  chances 
of  error.  But  one,  or  even  two,  of  these  three  probable  signs  may 
be  more  or  less  absent,  obscuring  the  diagnosis.  On  the  other  hand, 
each  of  these  three  signs  may  be  the  consequence  of  pathological 
states  clearly  distinct  from  pregnancy.  I  shall  only  mention  these 
different  causes  of  error,  not  having  space  for  a  complete  differ- 
ential diagnosis. 

1.  Modifications  of  the  breasts  (development  of  the  gland,  presence 
of  the  colostrum,  and  pigmentation  and  development  of  Montgomery's 
tubercles). — The  last  two  signs  are  of  a  very  different  appreciation. 
It  is  necessary  to  have  known  the  areola;,  and  to  have  preserved  an 
ct  memory  to  appreciate  the  changes.  Simple  extemporaneous 
observation  cannot  be  sufficient,  except  in  rare  instances. 


The  Diagnosis  of  Pregnancy.  161 

The  augmentation  of  volume  is  also  produced  under  the  influence 
of  adipose  deposit,  in  cast's  where  the  dinultani  elopment  of 

the  ahdomen  may  also  Lead  to  a  Buppo  itii  a  of  pregnancy. 

With  regard  to  the  presence  of  colostrum,  it  has  actual  im- 
portance only  in  the  primiparse,  for  in  women  who  have  had 
children,  and  especially  those  who  have  nursed  children,  then-  may 
be,  for  a  long  time  after  weaning  and  in  particular  at  the  menstrual 
period,  some  drops  of  colostrum  in  the  nipple.  In  the  primiparaa 
this  sign  becomes  of  influence  in  the  diagnosis  of  possible  pregnancy, 
but  it  is  necessary  to  guard  against  making  it  a  positive  sign,  for 
colostrum  is  sometimes  met  after  prolonged  genital  excitation-  or 
in  consequence  of  some  uterine  affections,  even  in  virgins. 

2.  Cessation  oj  the  menses.— The  different  causes  of  amenorrhea, 
including  pregnancy,  may  be  arranged  as  follows: 

A.  Extra-genital  causes. 

1.  General  diseases. 

a.  Acute.— Typhoid  fever,  etc.,  causing  a  simple  passing 

amenorrhea. 

b.  Chronic. — Chlorosis ;  phthisis;  poisoning;  anaemia, from 

deprivation  or  unsanitary  surrounding.  In  fact,  any 
debilitating  cause  may  produce  amenorrhea. 

2.  Localized  Diseases. 

a.  Acute. — Any  acute  disease  is  capable  of  causing  a  mo- 

mentary amenorrhea.  A  sudden  impression,  an 
emotion,  the  action  of  cold,  an  indigestion,  the  use  of 
exciting  drinks,  certain  medicaments  (opium),  bleed- 
ing, act  the  same. 

b.  Chronic— Prolonged  suppuration,  etc.    Am  cause  of  de- 

1  .ilitation.  Intestinal  worms,  by  reflex  reaction,  cause 
amenorrhea. 

B.  Genital  causes. 

1.  Genital  diseases. 

All  diseases  of  the  uterus  and  of  the  contiguous  organs  are 
capable,  to  different  degrees,  of  causing  a  more  or  less 
prolonged  amenorrhea.  Excess  of  coition  or  the  first 
coition,  may  act  in  the  same  way. 

2.  Physiological  causes. 

Pregnancy,  lactation,  menopause. 

3.  Genital  malformation. 

Absence  or  atrophy  of  the  ovaries  or  of  the  uterus. 
■4.  Genital  mutilations. 

Ablation  of  the  ovaries  or  of  the  uterus. 
Cicatricial  occlusion  of  the  genital  canal. 


162  The  Diagnosis  of  Pregnancy. 

3.  Augmentation  of  the  volume  of  the  uterus. — The  different  causes 
capable  of  producing  an  increase  in  the  volume  of  the  uterus  are : 

I.  Principal  causes  that  may  simulate  an  increase  in  the  size  of 

the  uterus  and  that  may  produce  errors : 
a. — Ovaries:  cysts,  cancer. 

b. — Broad  ligaments  :  cysts,  phlegmon,  salpingitis. 
c. — Bectuni :  cancer. 
d. — Bladder  :  retention  of  urine,  cancer. 
e. — Peritonaeum  :  pelvic  peritonitis,  extra-uterine  pregnancy, 

hematocele. 
/. — Pelvis  :  osteo-sarcoma. 
g. — Tympanites,  adipose,  ascites,  and  all  abdominal  tumors 

causing  an  increase  in  the  size  of  the  abdomen. 

II.  Cause  of  augmentation  in  the  volume  of  the  uterus : 
a. — Menstrual  congestion. 

b — Metritis. 
c. — Simple  hypertrophy. 
d. — Haematometra,  physometra. 
e. — Mucous,  fibroid,  or  papillary  polypi. 
/. — Hydatid  or  dermoid  cysts. 
g. — Fibroids  (very  frequent). 
h. — Sarcoma  (very  rare). 
i. — Cancer. 
j. — Normal  or  pathological  pregnancy. 

Second  three  months. — The  first  part  of  pregnancy  is  characterized 
by  the  absence  of  the  positive  signs  and  the  last  by  their  presence. 
In  the  second  three  months,  intermediate  between  these  two  periods, 
these  signs  appear : 

Sometimes,  and  rarely,  at  the  beginning  (fourth  month). 

Sometimes,  and  generally,  in  the  middle  of  this  period  (fifth 
month). 

Sometimes,  exceptionally  late,  toward  its  termination  (sixth 
month) . 

Now,  before  the  appearance  of  these  positive  signs  the  diagnosis 
presents  under  the  same  condition  as  in  the  first  three  months  and 
we  may  relate  it  to  the  explanations  given  above.  After  their  ap- 
pearance the  diagnosis  is  much  simplified  and  will  be  established 
as  in  the  third  and  last  three  months  which  we  now  study. 

Third  three  months. — The  existence  of  the  positive  signs  generally 
renders  diagnosis  easy  during  this  period.    These  signs  are,  as  given  : 
Palpation.  1.  Abdominal  ballottement. 

2.  Active  movements  of  the  foetus. 
Auscultation.  3.  Foetal  heart  sounds. 

4.  Active  movements  of  the  foetus. 


The  Diagnosis  of  Pregnancy.  1G3 

Digital  examination.    ;">.  Vaginal  ballottement. 

<i.   I  detection  of  a  foetal  part. 

It  will  l>o  remarked  that  among  these  signs,  there  arc  three  which 
-imply  indicate  the  presence  of  the  foetus,  and  three  which  permit 
us  to  say  that  it  is  living.     These  are: 

a.  Sinn*  of  the  presence  of  the  foetus. 

1.  Abdominal  ballottement. 

2.  Vaginal  ballottement. 

3.  Detection  of  a  foetal  part. 

b.  Signs  oj  the  life  oj  the  foetus. 

1.  Palpation  of  active  movements. 

2.  Audition  of  fcetal  heart  sounds. 

3.  Audition  of  active  movements. 

These  signs  have  already  been  studied  in  detail  and  I  shall  not 
return  to  them. 

B.  Pathological  pregnancy. — Numerous  pathological  states 
may  complicate  pregnancy  and  obscure  its  diagnosis.  They  will  be 
studied  in  that  part  which  is  reserved  for  puerperal  pathology.  I 
shall  simply  enumerate  the  principal  conditions.  These  different 
complications  are,  passing  from  the  periphery  of  the  uterus  toward 
the  foetus : 

1.  The  various  abdominal  tumors;  cysts  of  the  ovary,  hydrone- 
phrosis, ascites,  and  extra-uterine  pregnancy. 

2.  Malformations  of  the  uterus,-  double  uterus. 

3.  Diseases  of  the  ovuline  appendages,-  hydatiform  moles,  hydram- 
nios, 

4.  Death  of  the  foetus,  multiple  pregnancy  (2  to  5),  monstrosities. 

5.  Finally,  the  persistence  of  the  menses  during  pregnancy. 

To  complete  this  chapter  there  remain  to  be  spoken  of,  the  age  of 
the  pregnancy,  that  is,  the  probable  date  of  delivery  (discussed 
under  the  duration  of  pregnancy),  the  volume  of  the  foetus  and  its 
situation  in  the  uterus,  and  finally,  the  question  relative  to  the 
probable  sex  of  the  child,  so  often  asked  of  the  accoucheur. 

Ahlfeld  has  attempted  measurements  to  determine  the  dimensions 
of  the  foetus,  but  his  results  are  of  little  practical  value.  To  appre- 
ciate the  volume  of  the  child  the  obstetrician  is  reduced  to  an 
approximate  estimation  based  on  the  knowledge  derived  from  pal- 
pation. 

We  have  seen  the  mode  of  determining  the  situation  of  the  foetus 
during  pregnancy,  by  palpation,  auscultation  and  digital  exami- 
nation, and  it  is  useless  to  review  this   subject. 

With  regard  to  the  diagnosis  of  the  sex  of  the  child,  a  question 
nearly  allied  to  that  of  procreation  of  the  sexes  at  will,  we  are  no 


164  Progress  and  Duration  of  Pregnancy. 

more  advanced  than  in  the  time  of  Mauriceau,  who  thus  expressed 
himself  on  this  subject :  "We  can  have  no  positive  knowledge  of  the 
sex  of  the  child  which  is  in  its  mother's  abdomen,  and  no  knowledge 
of  the  means  of  begetting  a  boy  rather  than  a  girl." 


CHAPTER  VIII. 


PROGRESS  AND   DURATION   OF   PREGNANCY. 
PROGNOSIS.-HYGIENE. 

A.  Progress.  —  During  the  first  three  months  the  uterus, 
although  but  little  developed,  is  the  source  of  painful  disturbances 
explained  by  reflex  action — nausea  and  vomiting  and  the  syncope. 
During  the  second  three  months  these  disturbances  usually  dis- 
appear. In  the  last  three  months  the  uterus  becomes  voluminous 
and  attains  the  upper  portion  of  the  abdominal  cavity,  interrupting 
the  action  of  the  stomach  and  especially  of  the  diaphragm.  Below, 
it  slowly  invades  the  pelvis,  disturbing  the  functions  of  the  rectum 
and  bladder.  Finally,  its  size  opposes  the  free  circulation  of  the 
pelvis  and  lower  limbs. 

B  Duration. — To  appreciate  the  average  duration  of  preg- 
nancy, it  is  necessary  to  know  exactly  the  moment  of  conception, 
that  is,  of  the  meeting  of  the  male  and  female  elements  — 
spermatozoid  and  ovule.  Unfortunately,  our  ignorance  on  this 
point  is  complete.  In  the  most  favorable  circumstances,  where 
there  has  been  a  single  sexual  connection  affording  exact  infor- 
mation as  to  the  moment  when  the  spermatic  fluid  was  deposited 
in  the  female  genital  organs,  we  are  still  at  a  loss  as  to  the  epoch 
of  conception,  for  the  spermatozoids,  according  to  Schroeder,  may 
preserve  their  fecundating  properties  for]  fifteen  days  (perhaps 
more)  before  meeting  the  ovule.  These  fifteen  days  make  exact 
calculation  impossible. 

This  vagueness  enveloping  the  moment  of  conception  naturally 
reacts  on  the  fixation  of  the  duration  of  pregnancy.  How  shall  we 
decide  on  the  duration  of  a  state  when  we  are  ignorant  as  to  its 
commencement  ?  To  discuss  the  length  of  pregnancy  and  to  attempt 
to  fix  it  within  one  or  two  days  is  to  take  a  perfectly  useless  trouble. 

However,  it  seems  that  we  can  admit,  as  an  approximate  and  a 
provisory  figure,  nine  solar  months,  or  two  hundred  and  seventy-five 
days.     By  leaving  a  contingent  ten  days,  five  before  and  five  after, 


Progress  and  Duration  of  Pregnancy.  165 

we  have  the  probable  duration  oi  pregnancy  oscillating  bel 
two  bundred  and  seventy  and  two  hundred  and  eighty  days.  I 
figures,  1  repeat,  only  indicate  the  probabilities.  Tim-  in  pr<  - 
of  this  uncertainty  we  are  justly  astonished  to  s<  e  authors  dilate  at 
great  length  on  the  study  of  prolonged  pregnancies.  Thi>  id< 
prolonged  pregnancy  has  taken  its  source  from  various  categories 
of  observations : 

The  first  comprised  the  cases  where  the  duration  between  the  lasi 
menstruation  and  delivery  has  been  greater  than  the  usual  time.  I 
can  cite  a  case  where  this  duration  was  three  hundred  and  thirty-five 
•lays,  and  cases  of  this  kind  are  far  from  being  rare.  But  in  such 
cases  it  is  wrong  to  suppose  conception  near  the  end  of  the  last 
menstruation,  since  this  can  not  be  proven,  and  the  negative  can  be 
supposed  as  well  as  the  affirmative. 

The  same  is  true  of  the  second  category  of  facts,  where  pregnancy 
has  been  the  consequence  of  a  single  coitus,  or  of  sexual  relations 
taking  place  within  a  short  interval  of  time.  The  possibility  of  a 
contingent  fifteen  days,  during  which  the  sperm atozoids  may  live 
in  the  female  genitalia  makes  cases  of  prolonged  pregnancy,  founded 
on  this  class  of  facts,  still  contestable. 

A  third  category  of  facts  comprehends  those  where  the  volume  of 
the  fcetus  is  greater  than  the  average,  and  corresponds  to  a  prolonged 
duration  between  the  last  menstruation,  or  a  single  coition  and 
delivery.  But  as  we  have  seen  women  delivered  at  the  usual  time 
of  pregnancy  of  a  very  large  fcetus  (4000  grammes  and  more),  we 
can  suppose  from  this  that  in  the  other  case  the  duration  of  preg- 
nancy has  been  normal. 

Finally,  in  a  fourth  class,  we  shall  rank  those  furnished  la- 
veterinary  obstetrics.  But  in  all  these  observations  the  prolongation 
of  pregnancy  remains  doubtful,  on  account  of  the  impossibility  of 
determining  the  exact  date  of  conception.  There  is  nothing,  then, 
permitting  the  affirmation  of  prolonged  pregnancy,  but  it  must  also 
be  added  that  there  is  no  proof  that  obliges  us  to  deny  its  possibility. 

It  is  not  sufficient  to  know  the  approximate  duration  of  preg- 
nancy, it  is  equally  necessary  to  be  able  to  predict  the  probable 
date  of  delivery.  This  determination  will  be  based  on  the  following 
signs : 

1.  Signs  furnished  by  interrogation. 

a.  Signs  of  the  commencement : 

1.  Last  menstruation. 

2.  Single  coition. 

3.  Appearance  of  sympathetic  phenomena. 

b.  Sign  in  the  middle  period  : 

4.  First  movements  of  the  foetus. 

c.  Sign  toward  the  end  : 

5.  Phenomena  of  descent  of  the  uterus. 


166  Progress  and  Duration  of  Pregnancy. 

2.  Signs  furnished  by  direct  examination. 

6.  Volume  of  the  uterus  and  of  the  foetus. 

7.  Engagement  of  the  foetal  part. 

8.  Modifications  of  the  cervix. 

1.  Last  menstruation. — The  time  which  most  often  separates  the 
iast  menstruation  from  delivery  is  two  hundred  and  seventy-five 
to  two  hundred  and  eighty-two  days,  with  a  minimum  of  two  hundred 
and  forty-six  days  and  a  maximum  of  three  hundred  and  twenty- 
eight  days. 

2.  Single  coitus. — Delivery  generally  takes  place  at  the  end  of  two 
hundred  and  seventy-five  days,  that  is,  nine  months  after  the  fecun- 
dating coitus,  with  a  possible  deviation  between  two  hundred  and 
forty-two  to  three  hundred  and  seventeen  days.  The  special  sen- 
sations felt  by  some  women  can  only  exceptionally  be  taken  into 
consideration. 

3.  Appearance  of  sympathetic  phenomena. — It  is  rare  that  these 
phenomena  (vomiting,  syncope,  development  of  varices,  etc.)  in- 
dicate the  exact  beginning  of  pregnancy,  for  in  most  cases  they  only 
appear  some  time  after  conception.  However,  some  women,  taught 
by  a  previous  pregnancy,  can  sometimes  recognize  the  beginning 
of  pregnancy  in  this  way. 

4.  First  movements  of  the  foetus. — The  first  movements  of  the  foetus 
are  most  often  perceived  in  the  course  of  the  fifth  month.  Rarely 
they  occur  before  this,  but  they  have  been  observed  in  the  course  of 
the  fourth  month.  It  is  equally  rare  for  them  to  appear  for  the  first 
time  during  the  last  four  months.  Exceptionally  women  feel  no 
foetal  movements  all  through  gestation  although  the  foetus  is  per- 
fectly healthy.  Few  women  can  state  exactly  the  precise  date  of 
the  first  foetal  movements.  When  this  moment  is  known,  we  shall 
be  right  in  supposing  that  delivery  will  take  place  in  about  four 
months  and  a  half,  but  this  diagnostic  point  is  very  variable,  for 
there  may  be  a  deviation  of  a  month  and  even  more. 

5.  Phenomena  of  descent. — In  the  majority  of  cases  the  descent  of 
the  uterus  appears  nul,  or  we  cannot  determine  it  from  the  infor- 
mation furnished  by  the  woman.  The  phenomenon  of  descent  in  the 
multiparas,  when  it  exists,  indicates  that  pregnancy  is  within  the 
last  fifteen  days  of  its  termination,  but  this  is  only  simple  proba- 
bility.    In  the  primiparous  woman  its  importance  is  nul. 

6.  Volume  of  the  uterus  and  foetus. — The  volume  of  the  uterus 
during  pregnancy  is  too  difficult  to  appreciate  exactly,  so  that  it 
yields  scarcely  any  information  as  to  the  date  of  delivery.  The 
height  of  the  uterus  in  relation  to  the  abdominal  wall,  however,  in 
Bpite  of  the  error  to  which  it  is  exposed,  furnishes  valuable  indices. 

In  the  relation  we  have: 

V<  lurth  month. — Fundus  of  the  uterus  a  little  below  the  umbilicus. 


Progress  and  Duration  of  Pregnancy.  L67 

Fifth  month. — At  the  Level  of  the  umbilicus. 
Sixth  month.  —Fundus  a  little  above  the  umbilicus. 

mth  month. — Three  fingers'  breadth  above  the  umbilicus. 
Eighth  month.— Six  fingers'  breadth  above  the  umbilicus. 
Ninth  month. — Nine  fingers1  breadth  above  the  umbilicus. 

7.  Engagement  of  the  foetal  part. — Though  the  information  fur- 
nished by  the  engagement  of  the  foetus  is  quite  vague,  we  can 
Buppo3e,  however,  that  in  a  primipara,  with  a  deep  engagement, 
delivery  will  occur  in  about  a  month,  and  in  a  multipara,  with  a 
deep  engagement,  delivery  will  not  be  later  than  fifteen  days.  But 
these  figures  are  approximate. 

8.  Modifications  of  the  cervix. — On  the  supposition  that  the  cervix 
is  effaced  during  the  latter  part  of  pregnancy,  we  would  have  the 
right  to  diagnosticate  the  date  of  delivery  from  the  length  of  the 
cervical  part  of  the  uterus.  But  as,  save  in  exception,  it  is  known 
to-day  that  effacement  often  occurs  during  labor,  such  reasoning 
cannot  be  admitted. 

With  regard  to  the  softening  of  the  cervix,  it  is  too  variable  in  its 
progress,  especially  in  multipara3,  to  constitute  a  important  element 
of  diagnosis. 

C.  Prognosis. — "We  can  say,  without  exaggeration,"  writes 
Sacombe,*  "from  experience  and  observation,  that  pregnancy  far 
from  being  a  disease  is,  if  I  may  express  myself,  a  certificate  of 
life  for  nine  months  that  nature  gives  to  the  pregnant  woman." 
To-day  we  believe,  on  the  contrary,  that  the  prognosis  of  the  majority 
of  diseases  is  aggravated  by  pregnancy.  We  shall  see  later,  apropos 
of  puerperal  pathology,  the  influence  of  the  different  pathological 
states  on  pregnancy. 

With  regard  to  the  prognosis  of  the  gestation  itself,  and  especially 
of  delivery,  it  depends  upon  divers  circumstances,  among  which 
must  he  cited: 

1.  The  conformation  of  the  pelvis. 

2.  The  situation  of  the  foetus  (presentation  and  position). 

3.  The  composition  of  the  urine  (albuminuria). 

From  these  comes  the  extreme  importance  of  exact  inquiry  on 
these  three  points  during  the  course  of  pregnancy. 

D.  Hygiene  of  pregnancy. — 1.  Digestive  system. — Except  in 
serious  digestive  disturbances,  alimentation  should  not  be  modified 
during  pregnancy.  Women,  usually  constipated,  are  more  so 
during  pregnancy  and  need  laxatives  or  enemas  to  avoid  intestinal 
accumulation  and  violent  efforts  of  defecation.  Slight  purgatives 
are  without  objection  but  drastic  remedies  should  lie  avoided.  If 
diarrhoea  occurs  it  should  be  combatted  by  the  usual  means. 

*  Elements  de  la  Science  of  Accouchements,  1801,  p.  93. 


168  Progress  and  Duration  of  Pregnancy. 

2.  Breasts. — The  clothes  should  not  compress  the  mammary 
glands,  so  as  to  allow  their  physiological  development.  Apropos  of 
lactation  we  shall  see  the  special  care  to  be  given  the  nipples,  which 
demand  preparation,  a  veritable  education  in  view  of  this  physio- 
logical function. 

3.  Sexual  relations. — The  physician  is  often  consulted  for  advice 
as  to  the  continuance  of  sexual  relations  during  pregnancy.  In 
cases  of  irritable  uterus  and  in  women  predisposed  to  abortion,  all 
sexual  relations  should  be  interdicted  during  pregnancy,  especially 
at  a  time  corresponding  to  menstruation.  It  will  even  be  wise  to 
prescribe  separate  beds  for  the  husband  and  wife,  the  vicinity  of 
the  husband  often  causing  a  genital  excitement  that  is  unfavorable 
to  the  calm  required  by  the  uterus  for  its  normal  development. 

4.  Medicaments  and  operations. — Any  drug  given  in  a  tonic  dose 
is  capable  of  producing  abortion.  Eemedies  prescribed  during 
pregnancy,  then,  should  be  given  in  relatively  small  doses.  There 
are  some  exceptions,  however,  for  example,  mercury  in  syphilis, 
and  sulphate  of  quinine  in  malaria,  where  an  energetic  action  is 
necessary. 

Can  a  pregnant  woman  undergo,  without  inconvenience,  a  surgical 
operation?    This  question  should  be  viewed  from  two  standpoints : 

1.  Does  pregnancy  interfere  with  the  consequences  of  an  oper- 
ation? The  answer  is  negative  for  the  majority  of  cases.  Gestation 
does  not  appear  to  interrupt  cicatrization  nor  predispose  to  com- 
plications. 

2.  May  the  operation  interrupt  the  course  of  pregnancy  ?  Every 
operation  exposes  to  abortion,  and  this  danger  increases  as  the 
genital  zone  is  approached.  But  very  often  intervention  interesting 
the  uterus  itself  (amputation  of  the  cervix,  ablation  of  fibroids  de- 
veloped in  the  uterine  wall)  have  not  been  followed  by  any  unfor- 
tunate result.  Besides  the  danger  of  abortion  is  not  in  relation  with 
the  gravity  of  the  operation,  as  some  women  continue  their  gestation 
in  spite  of  an  ovariotomy,  while  others  abort  after  the  extraction  of 
a  tooth.  In  the  presence  of  this  variability  of  results  it  is  prudent 
to  perform  during  pregnancy  only  operations  of  necessity. 

3.  Professions. — Certain  professions  are  unfavorable  to  the  normal 
evolution  of  pregnancy.  Some  are  exposed  to  poisoning,  such  as 
workers  in  lead,  caoutchouc  (sulphide  of  carbon),  tobacco,  others  to 
excessive  fatigue,  as  laundresses,  shop  girls,  sewing-machine  oper- 
ators, etc. 

4.  Clothing. — All  tight  clothing  should  be  proscribed.  The  corset 
should  be  as  loose  as  possible.  In  women  predisposed  to  varices  or 
(.edema  of  the  lower  limbs  the  garters  should  be  replaced  by  suspend- 
ing the  stockings  by  bands  attached  to  the  corset.  The  use  of  im- 
proper shoes  should  be  avoided.  In  nulliparous  women  the  relaxation 


tress  and  Duration  <•>  Pregnancy.  l»i'.' 

nf  the  abdomen  may  be  greatly  relieved  by  the  ase  of  a  hypo- 
ric  belt  on  condition  that  it  is  large  and  embraces  t!.  two- 

thirds  of  the  abdomen. 

5.  Exercise  and  voyages. — Souk-  women,  naturally  indolent,  profit 
in  their  pregnant  state  by  confining  themselves  to  an 

repose.  This  practice  is  deplorable,  daily  exercise  i->  necessary. 
On  the  contrary  we  mnst  restrain  the  imprudent  who,  in  spite  of 
their  condition,  continue  their  former  habits,  going  to  balls,  theal 
etc.  Carriage  riding  is  generally  favorable.  It  is  wise  to  dissuade 
from  horsemanship.  According  to  Irwin,  sea  voyages  predis]  - 
to  menorrhagias,  while  Engelman  states  that  railway  journey-  pro- 
duce delay  of  the  menses.  This  would  be  an  interesting  difference 
if  clearly  established.  However,  in  the  majority  of  cases  normal 
pregnancy  is  not  interrupted  by  these  factors,  even  prolonged.  But 
in  women  disposed  to  abortion  prudence  should  be  advised. 

6.  Toilrt. — Women  often  inquire  if  they  can  continue  the  use  of 
cold  water  for  their  ablutions,  the  same  as  before  pregnancy.     With 

ird  to  this  no  change  of  habit  is  necessary.  Hot  foot-baths 
should  be  avoided.  Sea  bathing  is  not  objectionable,  but  fatigue 
should  lie  avoided.  Hot  baths  are  favorable,  on  condition  of  being 
Bhort  mot  over  a  quarter  hour)  and  being  taken  at  30"  to  35c  C. 

The  vulvar  toilet  is  hygienic,  but  vaginal  injections  should  be 
proscribed  before  the  last  fifteen  days  of  pregnancy.  These  in- 
jections may  be  necessary,  however,  in  some  cases,  where  there 
exists  a  vaginitis,  for  example.  During  the  last  fifteen  day-  it  is 
well,  in  an  antiseptic  point  of  view,  to  advise  a  daily  injection  of  a 
bichloride  of  mercury  solution  1 1-4000). 


170  Accouchement.— Maternal  Phenomena. 


CHAPTER  IX. 


ACCOUCHEMENT.— MATERNAL  PHENOMENA. 

Accouchement  is  the  expulsion  of  the  ovum  from  the  maternal 
organism,  whether  the  ovum  be  in  the  uterus,  as  in  the  normal  state, 
or  outside  it,  as  in  extra-uterine  pregnancy.  According  to  the 
period  at  which  this  takes  place  accouchement  receives  various  de- 
nominations : 

1.  During  the  first  six  months — abortion. 

2.  During  the  last  three  months — premature  accouchement. 

3.  At  normal  term — accouchement  at  term. 

4.  After  normal  term — delayed  accouchement. 
Accouchement  is  generally  made  in  two  stages  : 

First  stage,  expulsion  of  the  foetus. 
Second  stage,  expulsion  of  the  appendages. 
There  are  then  two  successive  deliveries : 

1.  Foetal  expulsion  or  accouchement  properly  so-called. 

2.  Accouchement  of  the  annexes  or  delivery. 

Foetal  accouchement. — The  term  accouchement  employed 
alone  will  be  applied  exclusively  to  the  fcetal  expulsion,  as  opposed 
to  delivery,  that  will  be  reserved  to  designate  the  expulsion  of  the 
appendages. 

Labor  is  almost  synonymous  with  accouchement;  however,  this 
word  applies  more  particularly  to  the  modifications  of  the  genital 
organs  which  prepare  for  the  expulsion  (uterine  contraction,  opening 
of  the  parturient  canal,  etc.). 

Considered  according  to  its  difficulties  accouchment  is  called : 

1.  Normal,  physiological,  entocic,  when  the  foetus  presents  by  the 
vertex  and  when  no  difficulties  arise. 

2.  Abnormal,  pathological,  dystocic,  in  contrary  conditions. 
Or  again : 

1.  Spontaneous,  when  it  is  left  to  the  forces  of  nature  alone. 

2.  .  1  rtificial,  if  intervention  is  necessary.  However,  a  slight  inter- 
vention, for  example  that  which  consists  in  aiding  the  rotation  of 
the  head  with  the  finger,  is  not  considered  as  constituting  an  arti- 
ficial accouchement.     Besides,  these  limits  are  arbitrary. 

Maternal  phenomena. — The  contraction  of  the  uterus  and  its 
ssory,  that  of  the  abdominal  wall,  causes  the  successive  opening 


AccoucJiement. — -Maternal  Pht  mum  na.  171 

of  the  cervix,  of  the  vagina,  and  of  the  vulva.    Contraction  is  theo 
the  cause  and  the  opening  the  effect.    We  Bhall  study  these  two 

phenomena  ;  one  etiological,  the  other  the  result. 

A.   Uterine  contractions. — The  uterine  contraction  presents  th 
ntial  characteristics,  it  is  painful,  intermittent  and  involuntary. 

Painful. — The  pain  is  the  dominant  character  of  the  uterine  con- 
traction to  such  an  extent  that,  in  common  language,  these  two 
words  are  taken  (wrongly)  as  synonyms.  It  establishes  the  dif- 
ference between  the  uterine  contractions  of  pregnancy  and  those  of 
labor.  The  woman  Buffers  only  at  the  moment  when  labor  com- 
mences. 

Its  intensity  is  quite  variable.  Some  women  are  delivered  with- 
out a  trace  of  pain.  Others  suffer  so  dreadfully  that  they  prefer  to 
die  and  even  seek  death. 

The  character  of  the  pains  varies  according  to  the  peiiod  of  labor. 

a.  Period  of  dilatation  of  the  cervix. 

1.  Initial  pains. — Slight  pains  in  the  hypogastrium,  in  the  flanks 
and  especially  in  the  lumbar  region. 

2.  Preparatory  pains. — Sharper  than  the  preceding;  occupying 
the  same  situation  and  sometimes  radiating  along  the  thighs,  in  the 
track  of  the  crural  nerve. 

b.  Period  of  expulsion. 

1.  Expulsive  pains. — The  pain  takes  a  new  character,  because  the 
woman  at  each  contraction  feels  the  need  of  bearing  down.  Each 
pain  is  accompanied  then  by  a  more  or  less  energetic  effort  in  this 
direction.  The  radiations  along  the  lower  limbs  are  still  frequent 
but  occupy  by  preference  the  course  of  the  sciatic. 

2.  Conquassant  pains. — These  are  the  terminal  expulsive  pains,  of 
accrued  intensity,  from  the  excessive  dilatation  of  the  vulva  at  the 
moment  of  the  passage  of  the  fcetal  head. 

The  cause  of  the  pain  during  uterine  contractions  has  been  the 
subject  of  long  discussions.  But  it  is  known  that  the  pathological 
or  energetic  contraction  of  every  organ  provided  with  smooth  mus- 
cular fibres  produces  a  pain  designated  as  colic.  Now.  the  pains 
of  accouchement  are  only  uterine  colic.  All  the  uterus  is  painful 
during  uterine  contraction,  thus,  at  this  moment  compression  of 
the  abdomen  and  palpation  are  painful  to  the  woman.  Digital 
examination  is  equally  painful  when  the  ringer  drags  on  the  external 
orifice  of  the  uterus.  Generally  the  pain  disappears  in  the  interval 
of  the  contractions.  However,  when  the  contractions  are  very  fre- 
quent or  very  energetic,  as  at  the  end  of  labor,  it  is  not  rare  to  see 
them  almost  continuous,  with  exacerbation  at  the  moment  of 
muscular  activity. 

In  the  early  part  of  labor,  during  the  initial  contraction.-,  the 


172  Accouchement. — Maternal  Phenomena. 

patient,  who  is  walking  to  and  fro,  stops,  supports  herself  on  a 
chair  and  inclines  forward.  She  becomes  quiet,  the  face  contracts, 
some  oscillations  show  the  mute  suffering,  then  the  calm  returns 
ami  the  patient  is  momentarily  free.  Later  the  pains,  becoming 
more  intense,  elicit  cries,  clamorous  complaints,  mixed  with  words 
of  despair.  These  cries  are  more  and  more  marked  as  dilatation 
progresses. 

During  expulsion  efforts  complicating  the  situation  modify  the 
nature  of  the  cries  and  permit  a  practiced  ear  to  easily  recognize 
this  last  period  of  labor. 

Intermittent. — 

Initial  pains,  repeated  every  twenty  minutes,  duration 

thirty  seconds.* 
Preparatory  pains,  repeated  every  ten  minutes,  duration 

sixty  seconds. 
Expulsive  pains,  repeated  every  five  minutes,  duration 

ninety  seconds. 
Conquassant,  almost  continuous. 

The  intermittent  character  of  the  contractions  permit  repose  for 
the  uterus  and  the  re-establishment  of  the  foetal  circulation,  which 
is  more  or  less  disturbed  during  uterine  systole.  A  prolonged  con- 
traction, that  is,  uterine  tetanus,  causes  death  of  the  foetus  by  the 
arrest  of  its  circulation. 

Involuntary. — As  in  all  the  unstriated  muscular  structures,  the 
contractions  of  the  .uterus  are  independent  of  the  will.  However, 
some  conditions  are  capable  of  reflex  action,  of  modifying  the  in- 
tensity or  the  frequence  of  the  contractions.  Thus  they  are  seen  to 
diminish  under  the  influence  of  an  emotion  or  in  the  presence  of 
a  person  disagreeable  to  the  patient. 

In  opposition  to  the  uterine  contractions,  those  of  the  abdominal 
walls  are  essentially  voluntary,  and  some  women  can  retard  or  ad- 
vance delivery  by  regulating  their  intensity. 

.  Some  words  on  the  results  of  uterine  contraction.  The  uterus  by 
contracting  diminishes  the  vertical  and  antero-posterior.  We  have 
seen  the  influence  of  the  contraction  on  the  foetal  circulation.  The 
number  of  maternal  pulsations  is,  on  the  contrary,  increased 
throughout  its  duration  (Fig.  197).  When  the  bag  of  waters  is 
ruptured,  there  is  a  slight  flow  of  the  liquor  amnii  at  the  beginning 
and  the  end  of  the  contraction.  The  force  of  the  uterine  contraction 
varies  from  one  to  twenty  kilogrammes,  and  can  be  fixed  at  an 
average  of  ten  kilogrammes.  The  assistance  of  the  abdominal  con- 
traction is  capable  of  increasing  this  force  to  three  and  even  to  four 
times  the  power  (thirty  to  forty  kilogrammes). 

B.  Abdominal  contractions.  —  The  contraction  of  the  abdominal 

♦These  figures  only  represent  the  average,  they  are  subject  to  great  variation. 


Accouchement. — Maternal  Phenomena.  1 7:> 

muscles,  that  is,  the  expulsive  effort,  follows  at  an  advanced  period 
of  Labor,  usually  when  the  dilatation  of  the  uterine  orifice  is  com- 
plete and  when  the  foetal  part  is  supported  on  the  perinseum.  It 
commences  a  little  after  the  beginning  of  the  uterine  contraction 
and  ceases  a  little  before  its  termination.  The  expulsive  effort  is 
not  always  single  during  a  uterine  contraction,  three,  four  or  five 
efforts  may  be  observed.  The  abdominal  contraction  depends  upon 
the  will,  but  the  need  of  bearing  down  is  so  imperiously  impressed 
on  the  woman  that  she  cannot  restrain  from  it.  The  expulsive 
effort  may  exist  without  uterine  contraction,  and  take  place  some- 
times under  the  direction  of  the  accoucheur  to  terminate  a  very 
much  advanced  expulsion. 

Uterine  contractions. 


Maternal  pulsations. 


Fcetal  pulsations.' 


/ — 


FlG.  197. — Influence  of  uterine  contraction  on  the 
fcetal  and  maternal  pulsations. 

C.  Vaginal  contractions. — The  vagina,  endowed  with  an  unstriated 
muscular  coat,  is  contractile,  but  the  contractions  of  this  canal  are 
so  feeble  that  their  role  seems  almost  nul  in  accouchement  and  very 
rudimentary  in  delivery  itself. 

II.  Opening  of  the  cervix,  of  the  vagina  and  of  the  vulva. — The  two 
canals  which  must  successively  open  and  allow  the  passage  of  the 
foetus  are : 

The  cervix  uteri,  to  which  must  be  added  the  inferior  segment  of 
the  uterus. 

The  vagina,  terminated  by  the  vulva  and  sustained  by  the  peri- 
neum. 

Let  us  study  these  two  successive  openings : 

A.  Dilatation  of  the  cervix. — At  term,  the  uterus  is  constricted  by 
three  parts  (Fig.  198).  An  upper  thick  part,  called  the  superior 
segment  of  the  uterus  (divided  by  some  authors  into  median  and 
superior  segments).  A  thin  intermediate  portion,  separated  from 
the  preceding  by  the  uterine  circle  (or  Bandl's  ring).  This  is  the 
inferior  segment  of  the  uterus.  An  inferior  portion  is  comprised 
between  the  external  and  the  internal  orifice  constitutes  the  cervix. 

The  superior  segment  is  formed  by  the  body  of  the  uterus,  the 
cervix  remains  as  it  was  before  pregnancy,  but  with  regard  to  the 
origin  of  the  inferior  segment  there  are  three  theories.  The  first, 
that  of  Brandl  and  Braune,  attribute  its  formation  exclusively  to 
the  cervix.     The  uterine  circle  would  be  the  internal  orifice  and  the 


174 


Accouchement. — Maternal  Phenomena. 


effacernent  of  the  cervix  would  constitute  the  inferior  segment.  The 
second  theory  is  also  from  Bandl,  who,  modifying  his  first  views 
admits  that  the  inferior  segment  is  formed  in  part  by  the  cervix  and 
in  part  by  the  body  of  the  uterus.  Finally,  Waldeyer  and  Hof  meier 
have  sustained  a  third  theory,  according  to  which  the  inferior 
segment  is  formed  exclusively  by  the  body  of  the  uterus. 


Uterine  circle. 
Internal  orifice. 

External  orifice. 
Fig.  198. — Uterus  at  the  beginning  of  accouchement. 

I  believe  it  can  be  demonstrated  that  no  one  of  these  explanations 
is  satisfactory.  The  uterus  in  the  normal  state  and  before  con- 
ception is  composed,  in  fact,  of  three  parts :  The  body ;  the 
isthmus ;  the  cervix.  Now,  at  the  end  of  pregnancy,  the  body  con- 
stitutes the  superior  segment  of  the  uterus.  The  isthmus,  the 
inferior  segment.  The  cervix  remains  intact.  The  schemas  199, 
200  and  201  present  a  resume  of  my  idea. 


Body. 


Cervix. 


Fir;.  199. — Uterus  at  the  beginning  of  pregnancy.     The  inferior  segment 
is  at  this  period  of  pregnancy  formed  by  the  body. 

Thus  understanding  the  inferior  segment  and  the  cervix,  we  may 
study  the  effect  of  the  uterine  contractions  in  dilating  these  parts 


Accouchement. — Maternal  Phenomena. 


175 


for  the  passage  of  the  foetus.     Lei  lie  suppose  a  section  of  the 

inferior  part  of  the  gravid  uterus  (Figs.  202  to  208). 


Sup.  segment 
Inf.  segment 

Cervix 


Fig.  200. — Uterus  at  the  end  of  pregnancy.     The  inferior  segment 
is  formed  by  the  isthmus. 


Sup.  seg. 

Inf.  segment.  ,r 

Cervix  effaced.     ^.»— *"" 

Fig.  201. — Uterus  during  labor.     The  inferior  segment  is  at  this  moment 
(labor)  formed  by  the  isthmus  and  cervix. 


Figs.  202  to  208. — Effacement  of  the  cervix  and  dilatation  of  the  external  orifice. 

(Fig.  202,  cervix  not  effaced;  Fig.  203,  cervix  being  effaced;  Fig.  204.  cervix  being 
effaced:  Fig.  205,  cervix  efface'! :  Fig.  206,  dilatation  of  external  orifice;  Fig.  207, 
dilatation  of  external  orifice;  Fig.  20S,  dilatation  of  external  orifice.) 


170  Accouchement. — Maternal  Phenomena. 

The  point  a  is  the  section  of  the  uterine  circle. 

The  point  h  is  the  section  of  the  internal  orifice. 

The  point  c  is- the  section  of  the  external  orifice. 

The  line  rib  represents  the  wall  of  the  inferior  segment. 

The  line  ch  represents  the  wall  of  the  cervix. 

The  point  (I  marks  the  section  of  an  orifice  of  new  formation 
(Muller's  orifice). 

Now  the  opening  as  in  figures  202  to  205  is  called  effacement. 
While  that  occurring  in  figures  205  to  208  is  called  dilatation  (of 
the  external  orifice).  Effacement,  then,  is  the  disappearance  of 
the  cervix,  its  fusion  with  the  body  of  the  uterus,  or  better,  the 
fusion  of  the  cavity  of  the  cervix  with  that  of  the  body  of  the  uterus. 
Dilatation  is  the  opening  of  a  simple  diaphragm,  which,  after 
effacement,  separates  the  uterine  cavity  from  the  vaginal  cavity. 
But  there  is  no  advantage  in  thus  limiting  the  word  dilatation,  and 
it  is  better  to  apply  it  also  to  the  opening  of  the  internal  orifice  and 
to  the  cervical  cavity  as  well  as  to  that  of  the  external  orifice. 
When  there  have  been  indicated  the  length  of  the  cervix  (that  is,  the 
degree  of  effacement),  the  degree  of  dilatation  of  the  external  orifice, 
of  the  cervical  cavity  (if  it  exist)  and  of  the  internal  orifice  (if  still 
remaining),  the  explanation  is  sufficiently  clear. 

When  it  opens  progressively  under  the  influence  of  the  internal 
contraction,  the  external  orifice  is  : 
Sometimes  circular. 
Sometimes  oval. 
Sometimes  irregular  (cicatrices — cancer). 

The  thickness  of  the  cervix  varies  according  to  the  parity :  In  the 
primipara  there  is  a  marked  thinning;  the  edge  of  the  orifice  gives 
a  sensation  analogous  to  that  felt  in  touching  the  frsenum  of  the 
tongue.  In  the  multipara,  on  the  contrary,  the  contour  of  the 
cervix  is  thick,  analogous  to  the  lips  slightly  drawn  over  the  teeth 
by  their  intrinsic  muscles. 

The  rapidity  of  the  dilatation  of  the  external  orifice  varies  with 
parity  (about  ten  hours  in  the  primipara,  five  hours  in  the  multi- 
para), with  the  vigor  of  the  uterine  contraction,  with  the  state  of 
the  softening  of  the  cervix,  with  the  presentation,  with  the  state  of 
the  pelvis,  etc.  It  progresses  more  rapidly  in  proportion  as  it 
advances.  Its  progression  is  generally  regular;  however,  it  is  not 
rare  to  observe  an  arrest  during  a  half  hour,  an  hour,  or  even 
more.  This  interruption  may  be  renewed  several  times.  Some- 
times the  external  orifice  after  dilatation  to  the  extent  of  two  to  three 
finger's  breadth  may  even  reform.  The  pregnancy  resumes  its 
normal  course  to  a  reappearance  of  labor  after  a  variable  time. 
This  has  been  designated  as  retrocession  of  labor. 

During  dilatation  of  the  external  orifice  various  complications 
may  occur.     Among  these  I  shall  mention  oedema  and  lacerations. 


Accouchenu  nt. — Matt  rnal  l'h>  norm  na. 


177 


(EdiDiit  is  sometimes  generalized  ;u ouiid  the  cervix,  as  often  ob- 
served in  some  easi  -  of  prolonged  labor.  In  the  multipara  i| 
invades  and  thickens  the  free  border  of  the  orifici  Fig.  209).  In 
the  primipara  it  respects  the  frei  border,  which  preserves  it-  char- 
acteristic thinness  i  Fig.  •21m.  Sometimes  it  is  localized  to  a  portion 
of  the  cervix,  almost  always  to  the  anterior  lip,  as  observed  by 
preference  in  the  occipito-posterior  positions  on  acconnl  of  the  com- 
pression exercised  by  the  forehead  ;iLr;tin.-t  the  pubes. 


^HSP  V "' 

Fig.  209. — CEdema  of  the  cervix  in  the  multipara. 


M P* 


Fig.  210. — CEdema  of  the  cervix  in  the  primipara. 

Lacerations. — The  foetal  part  pushed  too  violently  by  the  utero- 
abdominal  contraction,  sometimes  produces  true  tears  which  are 
shown  (Fig.  211) : 


Fig   211.—  Laceiations  of  the  cervix. 


I.  Sometimes  as  a  simple  slit,  most  frequently  to  the  left,  on 
account  of  the  most  frequent  situation  of  the  occiput  to  this  side. 

II.  Sometimes  as  a  strip ;  the  path  of  this  laceration  leaves  the 
orifice  and  curves  parallel  to  the  periphery  of  the  cervix. 


178 


Accouchement. — Maternal  Phenomena. 


III.  Sometimes  as  a  button-hole,  without  affecting  external  os. 

IV.  Sometimes  as  a  circular  button-hole,  which  detaches  all  the 
inferior  portion  of  the  cervix,  separating  it  and  leaving  it  as  though 
set  in  a  socket. 


Fig.  212. 

Dilatation  of  one 
finger's  breadth. 


Fig.  213. 

Dilatation  of  two 
finger's  breadth. 


Fig.  214. 

Dilatation  of  three 
finger's  breadth. 


Fig.  215. 

Dilatation  of  four 
finger's  breadth. 


Fig.  216. 

Dilatation  of  five 
finger's  breadth  or 
palm  of  the  hand. 


Fig.  217. 

Dilatation  of  six 

finger's  breadth 

or  complete. 


Fig.  21S. —  Perinseal  ampliation  during  accouchement. 

The  degree  of  dilatation  of  the  external  cervix  is  estimated  by 
the  sense  of  touch.  The  older  authors  expressed  the  degrees  of 
dilatation  in  comparison  with  the  size  of  various  pieces  of  money, 


.  iccouchcment.—  Maternal  Phenomena.  179 

then  with  th.it  of  the  palm  of  the  hand  and  finally  as  complete. 
Borne  modern  authors,  particularly  Jiudiu,  have  proposed  esti- 
mation iii  centimetres.  But  pieces  of  money  vary  in  different 
countries  and  the  metric  system  has  not  been  universally  adopted 
so  that  it  is  preferable  to  estimate  the  degrees  of  dilatation  in 
finger  breadths  (Figs.  212-217). 

Dilatation  is  called  complete  when  the  periphery  of  the  external 
orifice  is  in  contact  with  the  pelvic  ring.  It  is  called  sufficient  when 
it  permits  the  passage  of  the  foetus.  This  last  condition  is  relative 
to  the  volume  of  the  child.  In  the  diagnosis  of  the  degree  of  dila- 
tation, it  is  necessary  to  keep  in  mind  some  causes  of  error.  These 
are:  A  circular  vaginal  fold.  Folds  of  the  scalp.  Large  hag  of 
water.  Thinning  of  the  cervico-uterine  segment.  Deviation  of  the 
uterine  orifice.  It  is  sufficient  to  know  these,  to  be  able  to  avoid 
error. 

B.  Opening  of  the  vagina  and  vulva. — The  vagina,  of  which  the 
vulva  may  be  considered  the  external  orifice,  opposes  by  itself 
only  a  feeble  insistence  to  the  progression  of  the  fcetal  part.  The 
hymen  alone,  in  some  primipara1,  is  capable  of  causing  an  obstacle 
of  some  importance.  But  the  vagina  lies  on  the  perimeum,  which, 
especially  in  the  primiparse,  opposes  a  serious  resistance  to  the  exit 
of  the  foetus.  From  this  arises  the  necessity,  for  the  vagina  as  for 
the  cervix,  of  a  veritable  labor  before  permitting  accouchement.  For 
the  description  of  the  vagino-vulvar  dilatation,  I  shall  suppose  a 
presentation  of  the  vertex,  the  most  common.  The  uterus  contracts 
and  aided  by  bearing-down  it  pushes  the  cephalic  extremity  into 
the  vaginal  canal,  which  has  a  direction  perpendicular  to  the  uterine 
axis.  In  this  way  the  fcetal  head,  forced  parallel  to  the  uterine 
axis,  tends  to  gouge  into  the  perineum  (Fig.  218).  The  perineum, 
essentially  contractile  and  retractile,  reacts  against  this  pushing 
from  the  uterus,  and  the  effect  of  these  two  forces  combined  is  to 
direct  the  fcetal  part  toward  the  vulvar  orifice. 

The  perinsemn  constitutes  a  sort  of  door,  swinging  one  way, 
flexible,  with  the  sacro-coccygeal  articulation  representing  the  hinge, 
and  the  inferior  part  of  the  vulvar  orifice  the  free  side.  This  door 
opens  under  the  fcetal  pressure,  first  in  its  posterior  part,  or  coccy- 
anal,  then  in  its  anterier  part,  or  ano-vulvar. 

1.  Coccy-anal  ampliation. — The  head  presses  first  on  the  coccyx, 
which  it  pushes  backward.  But  the  coccyx,  solidly  maintained  on 
each  side  by  the  fibers  of  the  perinseal  levator,  opposes  a  serious 
obstacle  to  the  passage  of  the  head. 

2.  Ano-vulvar  ampliation. — The  progression  continues.  The  anus 
opens  by  degrees  (Fig.  219).  The  head  at  this  moment  appears  at 
the  vulva  then  retreats  in  the  interval  between  the  contractions. 
At  each  new  effort  the  head  advances  a  little  more  and  dilates  the 


180 


Accouchement. — Maternal  Phenomena. 


vulvovaginal  orifice.  Finally,  by  a  swinging  movement  the  bead 
issues  distending  tbe  perinseum  to  the  maximum  and  dragging  it 
forward.  As  soon  as  tbe  most  voluminous  part  of  tbe  foetal  region 
has  passed,  tbe  perinaeum,  which  lias  been  drawn  out,  retreats  un- 
covering tbe  fcetal  part.  Tbe  first  part  of  accouchement  is  com- 
pleted, one  of  tbe  ovoids  has  made  its  exit  and  the  other  escapes  by 
an  analogous  mechanism.  The  perinaeal  opening  has  been  dilated 
by  the  first  ovoid,  so  that  the  passage  of  the  second  is  made  with  a 
relative  facility. 


Fig.  218. — Perinseal  ampliation  during  accouchement. 


Fig.  219. — Perineo-vulvar  ampliation.     Opening  of  the  anus. 

During  this  ampliation  the  perineum  undergoes  an  enormous 
transverse  distention,  and  especially  antero-posterior,  so  that  the 
distance  wbicb  extends  from  the  inferior  extremity  of  the  sacrum 


Accouchement. — Maternal  Phenomena.  181 

to  the  fourchette  approximately  arrives  at  twenty  centimetre-,  four 

for  the  an. is  and  about  eij_rht  tor  the  retro-anal  (comprising  the 
coccyx  i  part  and  eight  tor  the  ante-anal  part.  Even  this  distance 
may  be  exceeded. 


FlG.  220. — Perineal  profile.     Perineal  lacerations.     Different  degrees. 

One  of  the  most  frequent  complications  of  accouchement  is  con- 
stituted by  wounds  of  the  vulva  and  of  the  perimeurn.  We  might 
Bay  these  wounds  are  the  rule,  for  out  of  one  hundred  cases  I  only 
found  the  vulva  intact  in  five.  Leaving  to  one  side  the  eccliymoses, 
which  compose  the  first  degree  of  vulvar  traumatisms,  we  can 
divide  wounds  of  this  region  into  three  categories : 

1.  Those  which  affect  the  inferior  or  posterior  part  of  the  vulva. 

2.  Those  which  occupy  the  latero-posterior  regions. 

3.  Finally,  the  complex  wounds — mixed  wounds  combining  the 
two  preceding. 

1.  Inferior  and  posterior  wounds. — Wounds  of  the  inferior  or  pos- 
terior part  of  the  vulva  are  those  which  are  usually  designated  as 
lacerations  of  the  perinaeum.  They  may  be  marginal  (Fig.  220)  or 
central  1  Fig.  221). 

2.  Latero-superior  wounds. — As  in  posterior  wounds  it  is  necessary 
to  establish  here  the  distinction  between  marginal  and  central 
laceration.  The  marginal  lacerations  extend  outward  from  the 
vulvo- vaginal  orifice  or  its  vicinity  and  are  directed  toward  the  free 
border  of  the  labia  minora  which  they  may  attain  (Figs.  222  to  225). 
The  central  lacerations  produce  a  veritable  perforation  of  the  labia 
minora,  analogous  to  the  central  laceration  of  the  perimeurn  (Fig. 
226). 

3.  Compter  wounds. — Complex  wounds  are  constituted  by  the 
association  of  the  two  preceding  varieties.  I  shall  not  return  to 
then-  description.  The  number  of  wounds  which  may  affect  the 
vulva  is  variable.  They  may  even  amount  to  eight  as  I  have  seeu 
(Fig.  227). 


182 


Aceoueiiement. — Maternal  Phenomena. 


Prognosis. — Vulvar  lacerations  expose  to  two  important  accidents : 
for  one  part,  to  hemorrhage  at  the  moment  of  accouchement,  es- 
pecially when  an  artery,  a  dilated  vein  (varices)  or  a  vascular  organ 
like  the  clitoris,  is  affected  ;  for  the  other  part,  during  post-partum, 
to  haemorrhage.  Wounds  well  cared  for  reunite,  at  the  perineum 
most  often  by  first  intention,  at  the  latero-superior  part  of  the 
vulva,  by  first  intention  in  some  cases,  in  others,  and  more  often, 
by  second  intention. 


Vulva. 


Central 
laceration. 


Fig.  221. — Central  laceration  of  the  perineum  (J.  Y.  Simpson). 

Treatment. — The  treatment  of  vulvar  lacerations  is  preventive 
and  curative. 


A.  Preventive  treatment. — 1.  Perinao-vulvar  dilatation. — Formerly 
a  series  of  manoeuvres  were  practiced  to  hasten  the  opening  of  the 
vulva  and  of  the  cervix,  but  these  have  been  justly  abandoned,  for 


Accouchement. — Maternal  Phenomena. 


L88 


their  influence  is  more  unfavorable  than  salutary.  Others  have 
advised  various  methods,  such  as  drawing  back  the  perinaeum  with 
two  fingers,  or  using  three  fingers  in  the  form  of  a  cone,  to  afford  a 
prsefoetal  dilatation. 


Fig.  222. — Two  lacerations. 


FlG.  223. — Three  lacerations. 


Fig.  224. — Three  lacerations,  one  of  Fig.  225. — Three  lacerations,  one  of 
which  affects  the  free  border  of  the  right  which  affects  the  free  border  of  the  left 
labia  minora.  labia  minora  ariil  another  the  fourchette. 

•2.  Perineeo-wlvar  support. — In  the  double  aim  of  moderating  the 
rapidity  of  the  foetal  exit  and  of  giving  the  foetus  the  direction  de- 
manding the  least  distention  of  the  maternal  parts,  it  is  important 
to  support  the  perinasum.  For  this  the  hands  will  lie  placed  dif- 
ferently according  to  the  position  taken  by  the  woman  during  labor. 


184 


Accouchement. — Maternal  Phenomena. 


Fig.  226. — Perforation  of  the  left  labia         Fig.  227.  —  Complex  wounds   of   the 
minora  (black  point).  vulva  (8). 

In  the  dorsal  position,  the  buttocks  are  uplifted  by  means  of  a 
cushion,  in  such  a  way  as  to  permit  easy  inspection  of  the  genital 
organs.  The  legs  are  flexed  and  the  thighs  widely  separated.  The 
physician  placed  to  the  right  of  the  woman,  passes  the  right  hand 
under  her  right  thigh  and  applies  it  on  the  perimeum  (Fig.  228), 
taking  care  not  to  cover  the  fourchette,  so  that  the  eye  can  follow 
its  modifications.  The  other  hand  is  placed  on  the  fcetal  head  to 
maintain  it.  The  fcetal  part  is  thus  solidly  held  by  the  accoucheur, 
directly  by  the  upper  hand,  mediately  through  the  perinseum  by  the 
lower  one.     Its  exit  is  thus  regulated  at  will. 

In  the  lateral  position  the  woman  is  placed  so  that  the  buttocks 
correspond  to  the  edge  of  the  bed  and  the  thighs  are  flexed,  making 
almost  a  right  angle  with  the  trunk.  The  upper  thigh  should  be  a 
little  more  flexed  than  the  lower  and  between  them  will  be  placed  a 
pillow  rolled  on  itself,  or  any  cushion,  to  keep  the  limbs  separated. 
The  right  hand  (Fig.  229)  supports  the  perimeuni,  as  in  the  dorsal 
position,  the  other  passed  around  the  upper  thigh  supports  the  head. 

3.  Episiotomy. — To  avoid  extended  tears  of  the  perinseum  vulvar 
incisions  have  been  proposed.  The  different  procedures  advised 
are  united  in  the  schema  of  Figure  230. 

Ritgeii. — A  series  of  radial  incisions. 

Eichelberg. — One  or  two  large  latero-inferior  incisions. 

Michaelis. — Posterior  incision. 

Tarnier  and  Chantreuil. — Incision  of  Michaelis  completed  in- 
feriorly,  either  on  a  single  side  (in  L),  or  on  both  sides  (in  a  re- 
versed Y). 


AfcoiK-lniit,  at. — Maternal  Phenorm  na. 


185 


Fig.  22$.—  Dorsal  or  French  position. 


£r 


Fig.  229. — Lateral  or  English  position. 


186  Accouchement. — Maternal  Phenomena. 

These  incisions  can  be  made  with  the  scissors  or  with  a  blunt- 
pointed  bistoury. 


>      \ 

/     ETchelberg    \ 

\5  | 

\    I 

Fig.  230. — Different  procedures  of  episiotomy. 

Ritgen's  procedure  is  insufficient.  That  of  Eicheiberg  has,  it  is 
said,  the  disadvantage  of  often  wounding  the  duct  of  Bartholin's 
gland,  and  of  causing  section  of  nervous  filaments  that  remain  pain- 
ful after  cicatrization.  Michaelis'  procedure,  completed  at  need  by 
the  incisions  advised  by  Tarnier  and  Chantreuil,  appears  inferior  to 
that  of  Eicheiberg  and  I  believe  the  disadvantages  of  the  latter  have 
been  exaggerated. 

B.  Curative  treatment. — When  the  perineal  lacerations  are  of 
small  extent,  not  exceeding  half  of  the  vulvo-anal  portion,  they 
often  cicatrize  by  first  intention,  provided  the  lower  limbs  are  tied 
together  at  the  knees  for  two  or  three  days. 

To  keep  the  two  lips  of  the  wound  together  the  employment  of 
serre-fines  has  been  advised.  But  applied  on  the  perinseum  they 
are  easily  displaced,  cause  painful  dragging  and  are,  in  a  word,  in- 
ferior to  sutures. 

Perineorrhaphy  should  be  performed  every  time  the  perineal 
laceration  is  of  much  extent,  and  especially  if  it  is  complicated. 
As  a  contra-indication  has  been  given  a  too  marked  contusion  after 
a  laborious  accouchement,  but  it  is  always  better  to  attempt  an 
immediate  perineorrhaphy,  being  prepared  to  see  it  fail  in  unfavor- 
able cases. 

Leaving  aside  the  latero- superior  wounds,  which  rarely  claim 
attention,  the  therapeutics  of  lacerations  will  be  as  follows : 


Accouchement. — Maternal  Phenonu  na. 


187 


1.  Laceration  of  the  first  degree  (limited  to  the  fourchette),  do 
treatment  necessary. 

2.  Laceration  of  the  second  degree  (from  the  fourchette  to  the 
anus)  (Fig.  281). 

a.  Slight  laceration.  Simple  fixation  of  the  lower  limbs  together 
for  one  to  three  days.  No  sutures  unless  the  patient  is  unruly  or 
the  nurse  inexperienced. 

b.  Extended  laceration.  Superposed  sutures,  one  centimeter  apart. 


Fig.  231. — Serre-fine. 


Sfc£M£KT 
CBRyjDL 

YAJGINA 

Fig.  232. — Genital  passage. 


3.  Laceration  of  the  third  degree  (or  complicated) :  a  deep  and 
extended  suture,  a  series  of  sutures  as  in  the  preceding  case.  At 
need,  buried  suture  of  the  recto-vaginal  septum.  In  the  case  of 
central  laceration  of  the  perinaeum,  we  also  have  recourse  to 
sutures,  uniting  the  separated  surfaces  in  all  their  extent. 

Arrived  at  the  close  of  this  study  of  the  maternal  phenomena,  let 
us  take  the  whole  at  a  glance.  The  schema  of  Fig.  232  represents 
the  canal  through  which  the  foetus  must  pass  from  the  fundus  of 
the  uteras.  The  thick  part  expels  the  foetus  by  its  contraction,  its 
role  is  essentially  active ;  the  thin  part,  on  the  contrary,  is  a  long 
irregular  sphincter  which,  both  active  and  passive,  opens  and 
dilates  to  allow  the  passage  of  the  uterine  contents.  Accouchement 
is  only  the  struggle  between  the  thick  part  and  the  thin  part  of  the 
genital  organs.  Delivery  (extended  to  the  expulsion  of  all  the 
ovum)  is  the  victory  of  the  thick  segment  over  the  thin  segment ;  it 
is  the  denouement  of  the  struggle  which  lasts  a  variable  time. 


188 


Accouche  mo  it. — Phenomena  of  the  Appendages. 


ACCOUCHEMENT.— PHENOMENA  OF   THE 
APPENDAGES. 

A.  Bag  ofivaters. — The  bag  of  waters  is  constituted  by  that  part 
of  the  ovuline  membranes  left  bare  by  the  dilatation  of  the  uterine 
orifice.  It  is  necessary  to  avoid,  as  too  often  occurs,  the  use  of  the 
term  ovuline  membranes  as  a  synonym  for  bag  of  waters,  for  the 
latter  represents  only  a  part  of  these  membranes.  Its  formation 
is  caused  by  the  dilatation  of  the  cervix.  The  bag  of  waters  may 
present  any  one  of  the  various  forms  of  the  schema  in  Fig.  233.  In 
the  first  variety  (flat)  there  is  only  a  thin  layer  of  liquid  interposed 
between  the  foetal  part  and  the  membranes.  In  the  projecting 
variety  we  have,  according  to  the  degree :  (a)  the  hemispherical 
form ;  (&)  the  cylindrical  form ;  (c)  the  piriform  variety. 


Fig.  233. — Different  varities  of  the  bag  of  waters. 

The  bag  of  waters  is  smooth  when  it  is  formed  by  a  portion  of 
the  membranes  distant  from  the  placenta,  but  it  becomes  more  and 
more  unequal  as  it  approaches  the  placental  disc.  These  inequal- 
ities may  serve  as  a  guide  to  the  probable  situation  of  the  placenta. 
Sometimes  it  happens  that  the  finger,  passed  over  the  membrane, 
perceives  in  their  thickness  pulsations  synchronous  with  the  fcetal 


Accouchement. — Phenomena  of  the  Appendages.  189 

pulsations.  This  3ign  reveals  the  presence  of  vessele  passing  to  an 
accessory  or  erratic  cotyledon  or  to  a  velamentous  insertion  of  the 
cord. 

The  membranes  are  permeable,  so  that  the  surface  of  the  bag  of 
waters  always  presents  a  marked  humidity.  This  permeability 
plays  an  important  part  in  the  formation  of  "the  show." 

At  a  given  moment  the  membranes  rupture,  the  amniotic  liquid 
is  liberated,  the  ovum  is  open.  By  studying  the  mode  of  rupture 
of  the  membranes  we  shall  see  at  the  same  time  the  constitution  of 
the  bag  of  waters.  The  membranes  may  rupture  in  two  totally  dif- 
ferent ways,  successively,  or  as  a  whole. 

Successive  rupture  takes  place  as  follows  :  The  cervix  opening 
and  giving  passage  to  the  foetus,  the  portion  of  the  membranes 
which  descends  first  and  constitutes  the  hag  of  waters  undergo. 
notable  distention,  much  more  marked  than  the  rest  of  the  ovuline 
envelopes.  The  decidua,  the  most  superficial,  soon  ruptures  leaving 
uncovered  a  part  of  the  chorion.  The  chorion  and  the  amnion, 
pushed  as  a  whole  by  the  liquor  amnii,  protrude  through  the  open- 
in  g  formed  by  the  rupture  of  the  decidua.  The  pushing  continues, 
the  projection  increases  and  a  new  rupture  follows,  but  contrary  to 
what  might  be  thought,  on  account  of  the  elasticity  of  the  chorion 
compared  with  the  resistance  of  the  amnion,  it  is  the  chorion  which 
ruptures  first.  This  is  because  its  adhesion  to  the  decidua  prevents 
its  descent  or  gliding  on  this  membrane  ;  all  its  ampliation  at  the 
has  of  waters  is  made  exclusively  by  its  elasticity  and  not  by  gliding. 
For  the  amnion,  on  the  contrary,  though  of  little  marked  elasticity, 
gliding  is  easy  on  account  of  its  feeble  adhesion  to  the  chorion,  so 
that  it  descends  without  difficulty.  Thus  a  rupture  of  the  chorion 
before  the  amnion  will  be  comprehended. 

The  amnion  remaining  alone,  to  constitute  the  bag  of  water,  con- 
tinues to  glide.  The  bag  descends,  pushed  by  the  amniotic  liquid 
and  the  fcetal  part.  This  gliding  of  the  amnion  produces  the  de- 
tachment that  is  easily  found  by  examination  of  the  appendages 
after  delivery.  When  this  gliding  is  interrupted  by  any  cause, 
compression  between  the  foetal  part  and  the  uterine  wall,  adhesion, 
placenta  inserted  in  the  inferior  segment,  too  great  thinness  of  the 
membrane  itself,  or  finally  under  the  influence  of  intervention  by 
the  accoucheur,  rupture  takes  place  as  for  the  chorion  and  decidua, 
the  ovum  is  opened,  the  amniotic  liquid  flows  away,  and  the  fcetus 
passes  through  tins  opening  by  enlarging  it. 

Aside  from  this  successive  rupture,  there  exists  rupture  as  a 
whole,  at  once.  The  three  membranes  are  ruptured  at  the  same 
place.  Their  union  remains  intimate,  they  all  three  succumb  at  once. 

According  to  the  results  I  have  obtained,  the  rupture  as  a  whole 
takes  place  in  40  per  cent  of  cases ;  successive  rupture  takes  place 
in  54  per  cent  of  cases.     Successive  is  then  the  most  frequent. 


190  Accouchement. — Phenomena  of  the  Appendages. 

The  situation  of  the  rupture  is  variable  and  may  occur  in  different 
places  (Fig.  234,  12  3). 


Fig.  234. — Different  places  of  rupture  of  the  membranes. 

In  relation  to  accouchement  the  rupture  may  occur : 

Before  labor — premature  rupture. 

During  labor — 1.  During  the  dilatation  of  the  cervix  (precocious 
rupture) ;  2.  at  complete  dilatation  (tempestive  rupture) ;  3.  during 
expulsion  (late  rupture). 

After  labor — delayed  rupture. 

Premature  rupture  takes  place  fifteen  days,  a  month,  sometimes 
even  more,  before  accouchement.  I  have  seen  a  case  where  it 
occurred  fifty  days  before  labor,  which  was  at  the  beginning  of  the 
ninth  month. 

Eetarded  rupture,  that  is,  after  the  ovum  has  been  expelled  as  a 
whole  and  at  term  is  quite  exceptional  (four  to  five  cases).  In  ex- 
pulsion before  term,  it  is  never  frequent. 

I  have  put  in  parenthesis  the  terms  "precocious,  tempestive  and 
late  rupture"  for  I  do  not  admit  these  distinctions  based  on  the 
erroneous  opinion  that  the  bag  of  waters  should  rupture  at  complete 
dilatation  in  the  physiological  state. 

It  is  probable,  save  some  exceptions,  that  the  rupture  of  the  bag 
of  waters  is  as  much  more  favorable  to  accouchement  as  it  is  late. 
Its  integrity  presents  a  double  advantage.  The  risks  to  the  fcetus 
are  less  when  the  ovum  is  complete.  With  regard  to  the  mother, 
it  is  certain  that  the  bag  of  waters,  forming  an  advance  guard  for 
the  fcetal  part,  favors  the  dilatation  of  the  cervix  and  the  ampli- 
ation of  the  perimeum  and  of  the  vulva.  This  cushion  of  waters, 
spreading  humidity  before  it,  exercises  a  soft  pressure  which  the 
maternal  tissues  obey  better  than  the  rude  compression  exercised 
by  the  foetal  part. 


Accouchement. — Phenomena  of  the  Appendages.  191 

Whatever  may  be  the  moment  o\  accouchement  when  rupture 

occurs,  it  takes  place,  sometimes  silently,  sometimes  with  a  noise. 
The  difference  depends  upon  the  quantity  of  water,  which  may  be 
free  to  flow  at  the  moment  of  rupture. 

The  diagnosis  of  the  rupture  of  the  hag  of  waters,  generally  easy, 
may  be  of  excessive  difficulty  sometimes.  Whenever  intervention 
is  necessary,  and  notably  the  application  of  the  forceps,  this  diag- 
nosis, however,  is  indispensable.  In  cases  of  a  premature  flow  of 
the  liquor  amnii,  the  knowledge  of  the  rupture  of  the  ovum  is  the 
basis  of  a  prognosis. 

For  the  answer  to  this  question  we  have  three  elements : 

1.  The  shrinkage  of  the  abdomen. 

2.  The  flow  of  liquid. 

3.  Digital  examination. 

1.  The  shrinkage  of  the  abdomen. — The  rupture  of  the  ovum,  some- 
times causing  the  evacuation  of  a  large  quantity  of  liquid,  may 
diminish  the  abdomen  so  markedly  that  the  patient,  and  even  the 
accoucheur,  will  perceive  it.  However,  this  sign  is  too  vague  to 
constitute  more  than  an  adjuvant. 

2.  The  flow  of  liquid. — "When  liquid,  of  the  same  color  as  the 
liquor  amnii  flows  troni  the  vagina,  after  having  eliminated  the 
possibility  of  an  involuntary  or  unconscious  micturition,  we  may 
question  whether  this  is  the  show  or  the  pure  amniotic  liquid. 

Differential  signs : 

THE    SHOW.  LIQUOR    AMNII. 

Stiffening  the  linen.  Not  stiffening,  or  only  a  little. 

Mucus,  thick.  Liquid,  not  stringy. 

Sometimes  sanguinolent.  Of  normal  color,  or  tinted  by  the  meco- 

nium, or  again  reddish,  red,  or  deep  red 
(maceration). 

Beginning  slow;  progressive  and  contin-  Beginning  sudden,  flowing  in  jets  and 

uous  flow.  intermittent. 

It  may  occur  that  the  liquor  amnii  has  actually  escaped,  and  yet 
in  digital  examination  one  may  still  feel  a  bag  of  waters  more  or 
less  filled  with  liquid.  There  exist  in  this  case  three  causes  of  error. 
The  first  is  the  existence  of  an  amnio-chorial  sac  (Fig.  235).  Now 
if  this  sac  exists  in  front  of  the  fcetal  part  it  may  be  ruptured  by  the 
finger  or  spontaneously.  The  liquor  amnii  flows  away  and  yet  on 
examination  there  is  met  (Fig.  236)  the  intact  amnion.  In  the 
second  place,  the  rupture  may  have  been  complete,  but  the  cervix 
retracting  after  the  flow  covers  the  opening  in  the  membranes 
(Fig.  237 1.  In  the  third  place,  the  rupture  of  the  membranes,  com- 
plete, while  remaining  outside,  the  uterine  orifice  is  obstructed  by 
the  approach  of  the  fcetal  part,  which  prevents  the  ulterior  flow  of 
liquid  (Fig.  238),  and  again  to  touch  there  appears  a  bag  of  waters. 

3.  Digital  examination. — The  diagnosis  of  the  integrity  of  the  bag 
of  waters  is  really  difficult  only  in  presentations  of  the  vertex,  for 


192 


Accouchement. — Phenomena  of  the  Appendages. 


in  the  other  presentations  the  volume  of  the  sac  and  the  inequalities 
of  the  fcetal  part  scarcely  permit  hesitation.  An  experienced  finger 
can  sometimes  recognize  the  hair  of  the  fcetus  and  diagnosticate 
the  absence  of  rupture.  During  contraction  the  sac  becomes  smooth 
and  tense.     The  fcetal  scalp,  on  the  contrary,  becomes  wrinkled. 

Amnion 
Chorion 

OeciduA 
Uterus 


Fig.  235. — Chorio-amniotic  sac. 

By  uplifting  the  fcetal  head  in  the  interval  between  contractions,  if 
a  flow  of  the  liquor  amnii  is  observed,  there  is  evident  proof  of  the 
rupture  of  the  ovum.  Finally  in  some  cases  the  speculum  has 
been  introduced,  but  this  mode  of  investigation  is  little  used.  The 
persistence  with  which  I  have  sought  to  establish  the  diagnosis  of 
the  rupture,  or  of  the  integrity  of  the  bag  of  waters  is  not  superflu- 
ous, for  the  hydrocephalic  head  has  been  perforated  at  the  bregma 
in  the  belief  that  the  operator  was  puncturing  the  membranes. 

Foetus. 
/     Amnion. 

Chorion. 
Uterus. 


»«w»w 


Fig.  236. 


Fig.  237. 


Fig.  238. 

P.upture  cf  chorion,  with  Rupture  of  the  membrane  above  Opening  of  the  rupture,  ob- 

amnion  intact.  the  uterine  orifice.  tructed  by  the  approach  of  the 

foetal  part. 

The  elements  of  prognosis  that  can  be  drawn  from  the  bag  of 
waters  depend  upon  its  volume  and  upon  the  period  of  rupture.  A 
flat  bag  of  waters  is  a  favorable  augury ;  projecting,  it  predicts  dys- 
tocia. All  things  being  equal,  the  later  the  rupture  of  the  bag  of 
waters  the  better  is  the  prognosis  for  the  mother  and  for  the  child. 
The  rale  should  be  to  leave  the  rupture  to  nature.     But  if,  to  follow 


Accouchement. — Phenomena  of  the  Appendages.  198 

some  -pedal  indication  (placenta  prsevia,  hydramnios,  Bpecial 
rigidity  of  the  membranes),  artificial  rapture  becomes  aecessary, 
the  membranes  may  be  opened  with  the  finger  nail,  which  sometimes 
presents  difficulties,  or  with  a  carefully  disinfected  instrument 
(Fig.  289).  Efthe  bag  of  waters  is  large,  the  rupture  should  be 
made  in  the  interval  of  the  contractions  and  the  hand  should 
moderate  the  flow  of  liquid  by  closing  the  vulva,  as  a  too  violent 
escape  favors  the  procidence  of  a  limb  or  of  the  cord. 


Fig.  239. — Membrane  perforater  of  whalebone,  with  ivory  point. 

B.  The  show. — The  ovuline  membranes,  when  they  are  no  longer 
reinforced  by  the  uterine  wall,  are  easily  permeable  for  the  liquor 

amnii,  especially  when  the  intra-ovuline  pressure  is  augmented  by 
the  contractions  of  labor.  Thus  when  accouchement  commences, 
in  proportion  as  dilatation  of  the  cervix  proceeds,  the  liquor  amnii 
filtering  through  the  membranes  escapes  along  the  vagina  and  from 
the  vulva  mixing  with  the  mucus  in  its  passage.  The  mixture  of 
liquids  constitutes  "the  show,"  which  is,  then,  part  ovuline  and 
part  maternal.  The  show  is  glutinous,  gelatinous,  due  to  the 
mixture  with  the  cervical  mucus  and  to  the  secretion  of  the  cervical 
glands.  This  consistency  favors  the  passage  of  the  fcetus  through 
the  parturient  canal.  In  general  the  show  is  of  a  citron  color, 
sometimes  streaked  with  blood.  Its  appearance  is  an  indication  of 
the  onset  of  accouchement.  With  a  dry  vagina  one  can  be  sure, 
save  in  a  pathological  state,  that  labor  has  not  commenced. 


194  Mechanism  of  Accouchement. — Foetal  Phenomena. 


CHAPTER  X. 


MECHANISM  OF   ACCOUCHEMENT.— FCETAL 
PHENOMENA. 

Whatever  the  presentation  may  be,  except  that  of  the  abdomen 
where  accouchement  is  impossible,  the  exit  of  the  foetus  takes  place 
in  six  stages : 

First  stage — diminution. 

Second  stage — engagement. 

Third  stage — internal  rotation. 

Fourth  stage — disengagement  of  the  first  ovoid. 

Fifth  stage — external  rotation. 

Sixth  stage — disengagement  of  the  second  ovoid. 

We  shall  examine  for  each  presentation  the  details  of  each  of 
these  stages. 

Presentation  of  the  "Vertex. — I  shall  take  as  the  type  the 
vertex  presentation  in  L  0  I  A,  the  most  frequent  position,  and  I 
shall  speak  later  of  the  mechanism  in  the  other  positions. 

1.  Diminution. — The  diminution  of  the  head  is  made  by  moulding 
and  by  inclination  of  the  dystocic  diameters  (flexion  and  lateral  in- 
clination). The  moulding,  resulting  in  the  deformation  of  the  head 
to  be  studied  under  plastic  phenomena,  is  brought  about  by  the 
over-lapping  of  the  bones  or  by  their  depression.  This  variety  of 
diminution  is  only  of  small  importance  in  presentations  of  the 
vertex.  The  inclination  of  the  dystocic  diameters,  on  the  contrary, 
takes  a  considerable  part,  it  occurs  by  flexion  and  lateral  inclination. 

Flexion,  by  directing  the  chin  towards  the  thorax,  approaches  to 
the  genital  axis  the  occipito-mental  diameter  (13^),  the  longest  of 
the  head.  A  moderate  flexion  substitutes  the  occipitofrontal 
diameter  (11-0  for  the  occipito-mental  and  a  very  marked  flexion, 
the  suboccipito-bregmatic  (9^)  for  the  occipito-mental  (Figs.  240, 
241  and  242).  By  each  of  these  degrees  of  flexion  there  is  gained 
two  centimetres ;  the  difference  in  the  circumference  belonging  to 
each  of  these  diameters  is  relatively  much  more  important.  The 
flexion  becomes  more  and  more  marked  in  proportion  as  the  head 
descends  into  the  bony  pelvis.  This  flexion  is  the  normal  attitude 
of  the  head  in  relation  to  the  trunk  and  the  pressure  of  the  vertebral 
column  during  the  uterine  contraction  only  exaggerates  it.  Flexion 
is  appreciated  in  digital  examination  by  the  relative  height  of  the 
bregma  and  lambda.     Easy  access  of  the  bregma  indicates  want  of 


Mechanism  of  Accouchement. — Foetal  Phenomena. 


195 


flexion.  In  proportion  as  the  lambda  approaches  the  center  of  the 
parturient  canal  the  head  is  flexed. 

The   lateral   inclination    favors   the   passage   of  the    trans' 
diameters  of  the  head,  in  particular  of  the  biparietal.     It  occurs 

amund  one  of  the  anteroposterior  diameters  of  the  head  as  a  pivot 
while  flexion  takes  place  around  a  transverse  diameter  passing  in 
the  vicinity  of  the  occipital  foramen.  With  regard  to  lateral  incli- 
nation it  is  necessary  to  understand  two  terms,  cynclitism  and  asyn- 
clitism. A  synclitic  head  is  that  where  the  two  parietal  protu- 
berances are  found  in  the  same  pelvic  plane,  at  the  superior  or  the 
median  straits,  or  at  any  region  of  the  excavation.  An  asynclitic 
head  is  that  where  the  two  parietal  protuberances  are  on  different 
planes.  Synclitism  maintains  the  sagittal  suture  in  the  center  of 
the  pelvis.  Asynclism  inclines  it  to  one  side.  Synclitism  is  un- 
favorable to  engagement  of  the  transverse  diameters  of  the  head 
and  asynclitism  is  favorable. 


Fig.  240. 

Presentation  of  the  occipito- 
mental diameter,  13); 
centimetres. 


Fig.  241. 

Presentation  of  the  occipito- 
frontal diameter,  n}4 
centimetres. 


Fig.  242. 

Presentation  of  the  suboccipito- 
bregmatic,  g%  centimetres. 


Now  does  the  head,  in  its  pelvic  passage,  descend  by  synclitism 
or  by  asynclitism  ?  According  to  Duncan,  whose  opinion  seems  to 
me  to  be  correct,  the  head  is  synclitic  at  the  superior  strait  and  in 
the  superior  part  of  the  excavation,  asynclitic  in  the  inferior  part 
of  the  excavation  and  at  the  inferior  strait. 

2.  En<i<t'~icment  is  the  descent  of  the  fcetal  part  from  the  superior 
to  the  median  strait,  the  same  as  disengagement  is  its  passage  from 
the  median  strait  to  the  vulvar  orifice.  Engagement  of  the  vertex 
occurs  usually  during  the  last  three  months  in  the  primiparae.  In 
the  multiparas  it  is  more  capricious  but  usually  takes  place  fifteen 
days  before  accouchement,  sometimes  sooner,  sometimes  later,  at 


196  Mechanism  of  Accouchement. — Foetal  Phenomena. 

the  moment  of  labor  or  even  only  after  complete  dilatation.  What 
has  been  said  on  the  epoch  of  engagement  supposes  the  absence  of 
all  causes  of  dystocia. 

Engagement  during  pregnancy  takes  place  under  a  double 
influence — the  influence  of  the  tonicity,  the  contractility  of  the  ab- 
dominal Avail  and  the  influence  of  utero-pelvic  muscles  (fibres  of  the 
broad  ligaments,  of  the  utero-sacral  ligaments  and  of  round  lig- 
aments). During  labor,  after  complete  dilatation,  the  action  of 
uterine  contraction  is  added  to  the  preceding  to  produce  engagement. 

The  engagement  is  usually  permanent,  that  is,  once  produced 
it  persists  to  the  end  of  pregnancy.  However,  intermittent  en- 
gagements have  been  noted,  the  foetal  part  ascends  after  a  mo- 
mentary descent  under  the  influence  of  the  utero-pelvic  muscles. 

Engagement  is  defined  by  the  region  of  the  pelvis  where  is  found, 
not  the  most  inclined  part  of  the  head,  but  the  largest  part  repre- 
sented by  the  biparietal  diameter.     We  say  then : 
Head  at  the  superior  strait ; 

Head  in  the  superior  or  inferior  part  of  the  excavation ; 
Head  at  the  median  strait ; 
when   the   biparietal  diameter  is  at  the    superior   strait,  in   the 
superior  or  inferior  portion  of  the  excavation,  or  at  the  inferior  strait. 

3.  Internal  rotation. — The  head  in  its  descent  accommodates  itself 
to  the  dimensions  of  the  parturient  canal  and  thus  is  placed  : 

Transverse,  at  the  superior  strait. 
Oblique,  in  the  excavation. 
Direct,  at  the  median  strait. 

The  rule  is  that  the  occiput  turns  forward,  the  exception,  as  we 
shall  study  under  anomalies,  is  backward  rotation ;  so  that  at  the 
median  strait  the  head  is  generally  found  in  the  occipito-pubic 
position.  There  have  been  long  discussions  as  to  the  reason  why 
the  occiput,  placed  transversely  at  the  superior  strait,  accomplishes  in 
descent,  its  evolution  forward  rather  than  backward.  The  reason  is 
probably  the  curve  of  the  parturient  canal,  as  its  axis  describes  an 
anterior  concavity  in  such  a  way  that  the  lowest  point  of  the  head 
is  naturally  directed  forward  to  follow  the  shortest  path  outward. 

4.  Disengagement.  —  The  disengagement  begins  at  the  median 
strait  and  terminates  at  the  vulva.  The  head  escapes  from  the 
muscular  pelvis  by  a  movement  of  extension.  Engagement  is  char- 
acterized by  flexion  of  the  head  and  passage  through  the  bony 
pelvis ;  disengagement  is  characterized  by  extension  and  passage 
through  the  muscular  pelvis  (Fig.  243). 

The  head,  pushed  by  utero-abdominal  contraction,  opens,  de- 
presses and  hollows  out  the  perinaeum.  This  structure  pushing  in 
the  opposite  direction,  there  result  two  opposed  forces  which  direct 
the  head  toward  the  vulvar  orifices.     In  this  movement  of  exit  the 


Mechanism  of  Accouchement. — Fcetal  Phenomena,  107 

head  is  bo  placed  that  the  occipitocervical  groove  comes  under  the 
symphysis  pubis  and  from  this  movement,  obeying  the  action  of 
the  perinseum,  it  accomplishes  around  this  groove  a  hinge  movement 
which  brings' successively  to  the  vulva  the  suboccipito-bregmatic, 
the  Buboccipito-frontal  and  the  suboccipito-mental  diameters,  in 
such  a  manner  that  there  appear  in  turn  at  the  perinseal  fourch<  tte 
the  nose,  the  mouth,  and  the  chin.  As  soon  as  disengagement  is 
terminated,  the  head,  no  longer  supported  by  the  perinaeum,  falls 
in  flexion. 


FlG.  243. — L  O  I  T  then  L  O  I  A.     Normal  engagement 
and  disengagement  in  O  P  (Schultze). 

5.  External  rotation. — From  the  utero-abdominal  contraction, 
which  follows  disengagement,  the  head  undergoes  a  movement  of 
external  rotation,  which  directs  the  occiput  to  the  left  (we  are  sup- 
posing a  LOIA).  This  external  rotation  of  the  head  is  only  the 
external  manifestation  of  the  internal  rotation  of  the  shoulders, 
which,  placed  transversely  at  the  superior  strait,  turns  like  the 
head  in  descending,  being  placed  first  obliquely,  then  in  the  coccy- 
pubic  diameter. 

6.  Disengagement  of  the  trunk. — Pushed  by  the  utero-abdominal 
contraction  the  cormic  ovoid  is  disengaged  little  by  little  at  the 
vulva,  where  appear  successively  the  throax,  the  abdomen,  and  the 
breech. 

Thorax. — The  most  difficult  part  of  the  thorax  to  deliver  is  the 
bisacromial  diameter.      Classic   authors  admit  that  the  anterior 


198  Mechanism  of  Accouchement. — Foetal  Phenomena. 

shoulder  first  appears  and  is  partially  disengaged  under  the  pubis, 
then  undergoes  a  movement  of  arrest,  during  which  the  posterior 
shoulder,  after  having  passed  over  the  vaginal  surface  of  the  peri- 
neum, is  disengaged  in  turn ;  the  anterior  shoulder  then  terminates 
its  exit. 

This  mechanism  is,  in  fact,  observed  quite  often,  but  I  believe  it 
to  be  pathological  and  due  to  the  action  of  the  weight  of  the  head 
which  thus  drags  the  anterior  shoulder  out  before  the  time  for  its 
normal  exit.  The  normal  mechanism  of  the  exit  of  the  shoulder  is, 
according  to  my  observation,  the  following:  While  the  anterior 
shoulder  is  arrested  and  hidden  behind  the  symphysis  pubis,  the 
posterior  shoulder  is  first  disengaged  from  the  vulva  and  after  its 
exit  the  anterior  shoulder  is  disengaged  in  turn.  This  mechanism 
only  takes  place  when  the  head  is  sufficiently  sustained  to  avoid  the 
pernicious  influence  of  its  weight. 

Abdomen. — The  abdomen,  a  soft  and  impressible  region,  is  dis- 
engaged without  difficulty.  During  its  exit  the  spine  ascends  slightly 
toward  the  pubis,  the  trunk  undergoing  a  slight  degree  of  rotation. 

Breech. — The  maternal  organs,  so  largely  opened  by  the  successive 
disengagements,  allows  the  foetal  breech  to  escape  easily,  sometimes 
abruptly,  one  hip  in  front,  the  other  behind,  as  in  the  case  of  the 
shoulders.  The  anterior  is  usually  disengaged  a  little  before  the 
posterior,  but  this  mode  depends  upon  the  direction  given  the  trunk 
of  the  foetus  and  is  of  little  importance. 

The  mechanism  in  each  position. — I  have  taken  as  the  type,  in  the 
description  of  the  mechanism,  L  0 1 A  ;  a  few  lines  will  be  sufficient 
to  complete  what  is  necessary  with  regard  to  the  other  positions. 

R  0 1  A. — The  internal  rotation  of  the  head  follows  the  same  as 
in  L  0  I  A,  the  occiput  under  the  pubes;  but  the  external  rotation 
occurs  in  such  a  way  that  the  occiput  turns  toward  the  right  side, 
while  it  was  directed  toward  the  left  in  L  0 1  A. 

In  a  general  way  we  can  say  that,  in  all  the  positions,  the  occiput 
in  the  fifth  stage  returns  to  the  side  where  it  is  found  in  the  interior 
of  the  genital  organs. 

L  0  IP. — The  interesting  point  in  the  mechanism  is  here  in  the 
third  stage  for,  the  same  as  in  the  previous  corresponding  position, 
the  occiput  turns  forward  to  be  placed  under  the  symphysis  pubis. 
The  occiput  turns  forward  because  the  head,  placed  in  the  occipito- 
pubic  position,  is  much  better  adapted  to  the  genital  canal  than  the 
occipito-sacral.  The  last  three  stages  present  no  peculiarity.  The 
external  rotation  of  the  occiput  is  made  to  the  left  as  in  L  0 1  A. 

B  01  P. — The  considerations  are  the  same  as  for  the  preceding 
position.  Internal  rotation  of  the  occiput  forward.  External  rotation 
of  the  occiput  to  the  right. 

I  shall  not  speak  of  the  transverse  positions,  as  they  are  converted 
into  the  oblique  in  the  excavation,  nor  of  tlie  direct  OP,  0  C,  which 


Mechanism  of  Accouchement, — Foetal  Phenomena.  199 

scarcely  exist  except  at  the  median  strait  and  -imply  represent  one 
of  the  moments  of  the  mechanism  ofthe  delivery. 

Irregularities  of  the  mechanism. — [irregularities  of  the  mechanism 
may  present  in  each  of  the  Btages  of  accouchement : 

1.  Pintiiiiititm.  —  The  cephalic  moulding  will  be  interfered  with 
when  ossification  is  too  much  advanced.  When  flexion  of  the  head 
is  insufficient,  a  presentation  of  the  brow  or  even  of  the  face  may 
arise.  Lateral  inclination  also  presents  variations  of  secondary 
importance,  and  which  cause,  especially  in  the  pathological  pelvis, 
inclined  presentations. 

2.  Engagement. — In  muciparous  women,  whose  soft  tissues  are 
very  supple,  the  same  utero-abdominal  contraction  sometimes  pro- 
duces both  engagement  and  disengagement,  bringing  the  head  from 
the  superior  strait  to  the  vulvar  orifice. 


Fig.  244. — R  O  I  T  then  R  O I  P.     Abnormal  disengagement 
of  the  head  in  O  S  (Schultze). 

3.  Internal  rotation. — The  movement  of  rotation  may  occur  too 
soon  or  too  late,  for  example,  when  the  occiput  only  turns  forward 
when  the  head  arrives  in  the  vicinity  of  the  vulva.  This  retardation 
is  frequent  when  the  foetus  is  small  or  the  pelvis  very  large.  The 
principal  anomaly  of  this  stage  of  accouchement  is  rotation  of  the 
occiput  backward.  In  the  occipito-posterior  position,  right  or  left, 
and  exceptionally  in  the  anterior,  the  occiput  may  turn  backward 
and  the  head  thus  be  placed  in  the  occipito-sacral  position.  The 
exit  of  the  head  then  takes  place  as  indicated  in  Fig.  244.  The 
occiput  passes  over  the  posterior  vaginal  wall,  the  head  is  flexed  in 


200  Mechanism  of  Accouchement. — Foetal  Phenomena. 

proportion  as  it  advances.  The  lambda  and  the  contiguous  part  of 
the  parietal  bones  are  first  disengaged  from  the  vulva  and  the  head 
is  extended.  When  the  occipito-cervical  groove  arrives  at  the 
fourchette,  there  appear  successively  at  the  superior  portion  of  the 
vulva,  the  bregma,  the  forehead,  the  nose  and  finally  the  chin. 
There  is  a  hinge  movement  analogous  to  the  occipito-pubic,  but 
here  it  is  produced  around  the  fourchette. 

4.  Disengagement  of  the  head. — The  rule  is  the  occipito-pubic  and 
I  only  recall  the  occipito-sacral  which  we  have  just  discussed.  A 
simple  mention  of  excess  of  slowness  or  of  rapidity  during  disen- 
gagement is  sufficient.  The  first  exposes  the  life  of  the  foetus,  the 
second,  the  integrity  of  the  maternal  perineum. 

5.  External  rotation. — This  rotation  may  not  occur,  the  shoulders 
being  expelled  from  the  vulva  transversely,  or  incomplete,  the 
shoulders  disengaging  obliquely.  Rotation  may  occur  in  an  opposite 
direction.  This  anomaly  is  due  to  an  excess  of  rotation  of  the 
shoulders  during  the  disengagement  of  the  head. 

6.  Disengagement  of  the  trunk. — We  have  seen  the  anomalies  of 
disengagement  of  the  shoulders.  The  irregularities  of  the  exits  of 
the  abdomen  and  of  the  breech  simply  depend  upon  the  situation 
of  the  vertebral  column.     Their  importance  is  secondary. 

Presentation  of  the  face. — I  shall  take  as  a  type  L  M  I  A. 

1.  Diminution. — Moulding,  extension  and  lateral  inclination.  The 
moulding  is  slight  with  regard  to  the  face  but  it  is  produced  on  the 
vault  of  the  cranium.  Extension  places  the  axis  of  the  cephalic 
ovoid  parallel  to  that  of  the  parturient  canal.  Lateral  inclination 
occurs  with  regard  to  the  bimalar  diameter. 

2.  Engagement. — The  engagement,  that  is,  the  descent  from  the 
superior  to  the  median  strait,  is  only  observed  during  labor  and 
usually  at  an  advanced  period  of  labor.  In  proportion  as  it  occurs 
extension  is  complete ;  the  chin  approaches  the  center  of  the  par- 
turient canal,  and  the  lambda  the  vertebral  column.  The  height 
of  the  head  in  the  pelvis  is  generally  designated  by  that  of  the  bi- 
malar diameter. 

3.  Internal  rotation. — This  movement  directs  the  chin  forward 
under  the  symphysis  pubis. 

4.  Disengagement  of  the  head. — The  head,  during  the  fourth  stage 
traverses  all  that  part  of  the  genital  canal  comprised  between  the 
median  strait  and  the  vulva.  This  disengagement  is  made  by  a 
movement  of  progressive  flexion.  The  chin  arrives  under  the 
pubic  symphysis,  which  is  exactly  applied  in  the  mento- cervical 
groove ;  around  this  the  head  executes  a  lunge  movement  and  there 
successively  appears,  in  front  of  the  perinatal  fourchette,  the  fore- 
head, the  bregma,  and  finally  the  occiput.  The  expelled  head  falls 
backward. 


Mi   hanism  oj  Accouchement.  —  Foetal  Phenomena. 


•2()1 


5.  External  rotation. — The  chin  turn.-,  to  the  side  to  which  it 
primarily  directed. 

r>.  The  disengagement  of  the  trunk  is  Bubjecl  to  the  sai  .  ler- 

ations  as  for  the  vertex  presentations. 

The  mechanism  in  each  position. — As  forthe       I       aly  the  oblique 
position  will  be  in  question  here. 

L  M  1  A  has  been  taken  as  the  type  and  described  already. 

B  M  1  A. — The  internal  rotation  turns  the  chin  forward,  and  the 
external  turns  the  chin  toward  the  right  thigh. 

L  M*  I  P. — The  internal  rotation  brings  the  chin  forward  and  the 
external  carries  it  toward  the  left  thigh. 

Pi  M  I  P. — Internal  rotation  of  the  chin  forward,  and  external 
toward  the  right  thigh. 


Fig   245. — LMIT  then  LMIA.     Normal  disengagement  ol  the  head 
in  MP  (Schultze). 

Irregularities  of  the  mechanism. — 1.  Diminution. — The  extension 
may  he  insufficient  and  render  engagement  difficult. 

2.  Engagement. — As  much  more  easy  as  the  extension  is  more 
marked.  More  rapid  in  the  mento-anterior  than  in  the  posterior. 
Prompt  in  a  large  multipara,  slow  and  painful  in  a  primipara. 

3.  Internal  rotation. — The  chin,  in  place  of  turning  forward,  may 
turn  backward  toward  the  coccyx.  This  becomes,  -  3hall  see, 
in  disengagement,  a  grave  cause  of  dystocia. 

4.  Disengagement  of  the  head. — When  the  rotation  of  the  chin  t- 
place  backward,  disengagement  cannot  take  place.     Accouchement 
in  a  mento-sacral  position  is  impossible.     I  deduce  from  this  the 


202 


Mechanism  of  Accouchement. — Foetal  Phenomena. 


following  therapeutic  conclusion,  which  should  be  graven  on  the 
mind  of  every  physician  :  Whenever,  in  a  presentation  of  the  face, 
the  chin  is  turned  backward,  it  is  necessary  to  bring  it  forward ; 
without  this,  even  with  the  aid  of  forceps,  accouchement  is  impossible. 
"Why  this  impossibility  ?  The  head,  in  a  face  presentation,  may  be 
divided  into  three  zones  (Fig.  2-16) .    The  first  is  exclusively  cephalic. 


Fig.  246. — The  three  cephalic  zones  of  tace  presentation. 

The  second  comprises  the  head  and  the  neck,  and  the  third  is  com- 
posed of  the  head  and  thorax,  with  the  dependent  shoulders.  Now 
the  first  two  zones  can  penetrate  without  difficulty  into  the  exca- 
vation, but  the  third  is  too  large  in  the  child  at  term  to  pass  the 
superior  strait.  When  the  chin  is  turned  forward  it  can  be  dis- 
engaged under  the  pubic  symphysis  without  the  necessity  of  the  en- 
gagement of  the  third  zone ;  but  when  it  is  turned  backward,  the 
disengagement  of  the  chin  in  front  of  the  fourchette  is  impossible 
without  the  engagement  of  the  third  zone. 

Let  us  retain  this  impossibility  as  the  rule,  in  a  practical  point  of 
view,  though  recognizing  that  there  exist  some  exceptions.  Mine. 
Lachapelle  has  observed  disengagement  in  a  mento-transverse  po- 
sition and  Smellie  has  even  seen  it  in  the  mento-saeral. 

5  and  6.  External  rotation  and  disengagement  of  the  trunk  present 
the  same  anomalies  as  in  vertex  presentations. 

Presentation  of  the  brow. — I  shall  take  as  a  type  E  M  I  T. 

1.  Diminution. — In  presentation  of  the  brow  there  can  be  no 
question  of  flexion  or  of  extension,  for  flexion  causes  transformation 
into  vertex,  and  extension  into  face  presentation.  The  head  is 
diminished  solely  by  moulding.  The  result  of  this  is  a  deformation 
characteristic  of  this  part  of  the  body  (see  plastic  phenomena). 


Mechanism  of  Accouchement. — Foetal  Phenomena, 


•jo:; 


2.  Engagement.  —The  head  remains  usually  ;i  Long  time  al  the 

superior  strail  and  engages  -till  later  than  in  presentation  of  the 

face.    The  head  descends  slowly  and  with  difficulty.    The  height 
of  the  head  is  designated  by  that  of  the  frontal  protuLeranci 


Fig.  247. —  Brow  presentation  in  R  M  I  T. 

3.  Internal  rotation. — As  in  the  other  presentations  of  the  cephalic 
ovoid  the  head  is  placed  transversely  at  the  superior  strait,  obliquely 
in  the  excavation,  and  direct  at  the  median  strait.  The  chin  in  its 
descent  usually  turns  forward;  exceptionally  it  turns  backward. 


Fig.  24S.— Disengagement  of  the  head  in  brow  presentation  :  mento-pubic. 

4.  Disengagement  of  the  head. 

a.  Mento-pubic. — The  head  descends  little  by  little,  depressing  and 
opening  the  pelvic  floor.  The  bregma  always  remains  in  the  center 
of  the  parturient  canal  or  near  it.  The  foetal  part  finally  arrives  at 
the  vulva  and  escapes  by  the  mechanism  represented  in  Fig.  248. 

h.   Mcnto-sacral. — The   head    having   passed   the   median   strait 


204  Mechanism  of  Accouchement. — Foetal  Phenomena. 

continues  its  descent.  The  occiput  strikes  against. the  symphysis 
pubis  and  a  swinging  movement  follows  which  carries  the  chin  out- 
ward first.     The  occiput  makes  its  exit  last  (Fig.  249). 


Fig.  249. — Disengagement  of  the  head  in  brow  presentation:  mento-sacral. 

•5  and  6.  External  rotation  and  disengagement  of  the  trunk  occur 
exactly  as  in  presentation  of  the  vertex. 

Media)! ism  in  each  position. — I  have  taken  as  the  type  for  de- 
scription a  E  M  I  T  at  the  superior  strait,  and  I  have  shown  the 
mechanism  according  as  the  chin  turns  forward  (EM  I  A,  M  P)  or 
backward  (E  M  I  A,  P  S).  The  same  considerations  apply  to  L  M 
I  T  according  as  the  chin  turns  forward  (L  M  I  A)  or  backward 
(L  M  I  P) ;  new  descriptions  are  useless. 


Fig.  250. — Disengagement  of  the  cephalic  ovoid  in  vertex  presentation. 

Resume. — All  authors,  who  have  described  presentation  of  the 
forehead,  have  endeavored  to  prove  the  analogy  between  the  mode 
of  exit  in  presentations  of  the  brow  and  of  the  vertex.  I  shall  not 
follow  this  demonstration.  In  place  of  seeking  the  analogy,  I  shall 
point  out  the  differences.  Presentations  of  the  vertex  and  of  the 
face  are,  as  well  as  their  mechanism,  normal,  physiological.  The 
cephalic  ovoid  presents  by  its  large  extremity  (Fig.  250)  or  by  its 
small  extremity  (Fig.  251),  which  descends  first  in  the  parturient 
canal  and  escapes  first  at  the  vulva,  making  easy  exit  by  a  swinging 
movement  of  the  remainder  of  the  ovoid.  It  is  otherwise  in  ac- 
couchement by  the  brow.  The  fcetal  part,  retained  at  the  superior 
strait,  pushed  in  a  vicious  direction,  remains  intermediate  between 


Mechanism  of  Accouchement. — Fcetal  Phenomena. 


24 15 


flexion  and  extension.  The  head  descends  in  spite  of  it-  vicious 
situation,  it  is  deformed  and  thus  badly  engaged,  badly  directed, 
and  is  obliged  to  issue  from  the  genital  canal  by  a  peculiar  mechan- 
ism, not  at  all  comparable  to  the  normal  physiological  mechanism. 
From  this  arises  numerous  difficulties  that  are  frequent  sourc« 
dystocia. 


Fig.  251. — Disengagement  of  the  cephalic  ovoid  in  face  presentation. 


Presentation  of  the  breech. — I  recall  in  Fig.  252  the  four 
varieties  of  presentation  of  the  breech:  Complete;  incomplete; 
variety  of  the  buttock;  of  the  knees ;  of  the  feet. 

I  shall  take  as  a  type  a  presentation  of  the  complete  breech  in 
L  S  I  A. 


Complete 
breech. 


Incomplete.    Variety 
of  the  buttocks. 


Incomplete.     Knee 
variety. 


Incomplete.     Foot 
variety. 


Fig.  252. — Varieties  of  breech  presentation. 

1.  Diminution. — The  diminution  may  be  compared  in  spite  of 
important  differences  to  the  molding  of  the  head  in  vertex  presen- 
tations. The  breech  undergoes  during  its  descent  movements  of 
flexion  and  extension  (bitrochanteric  axis)  or  of  lateral  inclination 
(sacro-pubic  axis),  analogous  to  the  movements  of  the  head  but  of 
less  importance.  It  is  sufficient  to  know  that  the  buttocks  are 
synclitic  at  the  superior  strait  and  asynclitic  at  the  inferior  strait, 
the  anterior  being  the  lower. 

2.  Engagement. — The  engagement  is  the  descent  of  the  breech 
from  the  superior  strait  to  the  median.  When  the  breech  is  com- 
plete engagement  takes  place  only  during  labor  and  even  at  an 
advanced  period  of  labor,  in  general  at  complete  dilatation.  The 
height  of  the  breech  will  be  indicated  by  that  of  the  bitrochanteric 
diameter. 


200  Mechanism  of  Accouchement. — Fcetal  Phenomena. 

3.  Internal  rotation. — The  bitroclianteric  diameter,  the  most  volu- 
minous of  the  pelvic  extremity,  rules  the  movement  of  rotation.  In 
spite  of  its  predominant  dimensions  the  bitroclianteric  diameter  is 
not  placed  transversely  at  the  superior  strait,  but  obliquely.  The 
cause  is  in  part  the  back,  in  part  the  smaller  members,  which  are 
pushed  aside  by  the  projection  of  the  vertebral  column  and  thus 
impede  the  transverse  accommodation  of  this  diameter.  The 
bitroclianteric  diameter,  oblique  at  the  superior  strait,  remains 
oblique  in  the  excavation,  and  is  placed  antero-posteriorly  at  the 
median  strait.  It  is  the  trochanter  nearest  to  the  pubes  (the  left 
in  L  S  I  A)  which  turns  forward, 

4.  Disengagement  of  the  trunk. — The  breech  advances  little  by  little. 
The  trunk  undergoes  a  lateral  inflexion  (Fig.  253)  analogous  to 
extension  for  the  vertex.  The  anterior  thigh  escapes  first  from  the 
vulva,  then  the  posterior.  Upon  the  arrival  of  the  abdomen,  the 
trunk  undergoes  a  very  slight  movement  of  rotation  which  inclines 
the  vertebral  column  a  little  forward.  This  movement  is  soon 
corrected  by  the  descent  of  the  shoulders,  which  are  placed  in  the 
antero-posterior  direction.  The  arms  are  against  the  trunk  (a 
contrary  condition  is  pathological),  the  elbow  appears  first,  then  the 
shoulder,  the  anterior  being  disengaged  first,  and  then  the  posterior 
(Fig.  254). 


Fig.  253. — Lateral  inflexion  of  the  trunk  in  accouchement 
by  the  breech  (Hodge). 

5.  External  rotation. — This  movement  will  be  comprehended  if  we 
observe  a  child  attempting  to  pass  between  two  bars  of  a  gate.  It 
engages  first  the  head,  the  face  looking  upward,  then,  for  the  trunk, 
one  shoulder  is  put  forward,  the  other  backward,  the  body  passes 
easily  now  if  the  space  is  sufficient.  The  child  has  unconsciously 
accomplished  the  movement  of  rotation,  which  permits  the  succes- 
sive adaptaion  of  the  head  and  trunk  to  the  space  through  which  they 
must  pass.     External  rotation  brings  the  vertebral  column  forward 


Mechanism  of  Accouchement. — Foetal  Phenomena, 


207 


so  that  the  head  is  placed  in  the  occipito-pubic  position.  Whether 
first  to  Last,  then,  the  head  becomes  occipito-pubic  in  issuing  from 
the  genital  organs. 

i).  Disengagement  of  the  hind. — The  head,  generally  aided  by  the 
accoucheur,  is  disengaged  by  a  swinging  movement,  or  by  a  hinge 
movement  around  the  pubes,  analogous  to  that  of  the  vertex  pre- 
Bensation,  but  the  head  being  turned  in  the  opposite  direction  there 
successively  escape  i'rom  the  vulva,  at  the  fourchette,  the  chin,  the 
mouth,  the  nose,  the  eyes,  and  the  forehead ;  after  the  passage  of 
the  frontal  protuberances  the  head  escapes  brusquely. 


Fig.  254. — Successive  disengagement  of  the  trunk  (variety  of  the  buttocks  is  here 
represented;    disengagement  is  the  same,  with  complete  breech). 

Mechanism  in  each  position  and  in  each  variety  of  presentation. — 

Position  (conqdetc  breech).  —  L  S  I  A  has  been  taken  as  the  type 
and  described  above. 

ESI  A. — The  right  buttock  turns  forward  from  left  to  right  to  be 
placed  under  the  pubes.  The  rotation  of  the  occiput  is  always  made 
under  the  symphysis  and  disengagement  is  occipito-pubic. 

LSI  P. — The  left  buttock  turns  forward  and  from  left  to  right. 

E  S  I  P.  —The  right  thigh  turns  forward  and  from  right  to  left. 

Varieties  of  presentation. — The  complete  breech  has  been  taken  as 
the  type  of  the  mechanism.  All  that  has  been  said  applies  to  this 
variety. 

Incomplete  breech,  variety  of  the  buttocks. — The  engagement  in  this 
variety  often  occurs  during  pregnancy.  This  precocity  is  due  to 
the  relative  diminution  of  the  foetal  pelvis  by  the  extension  of  the 


208  Mechanism  of  Accouchement. — Foetal  Phenomena. 

lower  limbs.     The  different  stages  are  executed  as  in  presentation 
of  the  complete  breech,  with  the  difference  that  the  extention  of  the 
impeding  the  movement  of  lateral  flexion. 
lower  limbs  renders  disengagement  of  the  trunk  more  difficult  by 

Incomplete  breech,  variety  of  the  knees  and  feet. — These  varieties  are 
only  constituted  at  the  moment  of  accouchement ;  they  are  second- 
ary. The  engagement  and  the  disengagement  of  the  trunk  are  more 
rapid,  on  account  of  the  diminution  of  the  breech.  The  exit  of  the 
head  is  relatively  more  difficult  than  in  the  other  varieties  because 
the  dilatation  of  the  maternal  parts  has  been  less  complete.  The 
first  parts  which  appear  at  the  vulva  are  naturally,  according  to  the 
variety,  the  feet  or  the  knees. 

Irregularities  of  the  mechanism — 1.  Diminution  may  be  difficult  on 
account  of  the  spreading  apart  of  the  lower  limbs. 

2.  Engagement  only  occurs  at  the-  superior  strait  when  the  breech 
presents  in  the  oblique  position.  In  the  sacro-pubic  or  sacral  the 
presence  of  the  lower  limbs  renders  this  difficult.  In  the  sacro- 
transverse,  the  bitrochanteric  diameter  finds  difficulty  in  passing  the 
promonto-pubic . 

3.  Internal  rotation. — The  internal  rotation  may  be  incomplete  or 
exaggerated  and  an  oblique  disengagement  results.  If  an  anomally 
of  rotation  places  the  bitrochanteric  diameter  transversely,  disen- 
gagement is  made  in  this  situation. 

Disengagement  of  the  trunk. — Besides  the  irregularities  which  have 
been  in  question,  the  arms  may  be  uplifted  in  the  attitude  of  diving. 
This  complication  is  the  result  of  tractions  on  the  trunk  and  is  not 
generally  observed  when  the  accouchement  has  been  left  to  the 
forces  of  nature  alone. 


Fig.  255. — Head  last  disengaging  in  occipito-sacral,  by  a  posterior  swinging 
movement  (disengagement  back  to  back). 

5.  External  rotation. — The  occiput,  in  place  of  turning  forward, 
may  remain  transverse  or  even  directed  backward.  Serious  diffi- 
culties of  disengagement  result  from  this. 

6.  Disengagement  of  the  head.  —  Occiput  transverse.  —  The  head 
escapes  somewhat  as  in  occipito-pubic,  only  a  hinge  movement  takes 


Mfchiinism  of  Arccmehi  ment. — Foetal  Phi  nonu  na. 


209 


place  around  one  of  the  ischio-pubic  rami,  and  all  the  elements 
the  face  successively  appeal  at  an  opposite  point  of  the  vulva. 


Fig,  256. — Head  last  disengaging  in  occipito-sacral,  by  an  anterior  swinging 
movement  (disengagement  abdomen  to  abdomen  . 

Occiput  posterior. — The  disengagement  is  executed  in  two  way- ; 
a.  By  a  movement  of  posterior  swinging  (Fig.  255) — a  hinge  move- 
ment is  made  around  the  fourchette  and  disengagement  back  to 
back  occurs,  b.  By  a  movement  of  anterior  swinging  (Fig.  250 1 — the 
chin  hooks  behind  the  symphysis  pubis,  the  head  is  progressively 
flexed,  the  occiput,  turned  backward,  arrives  at  the  vulva — the  dis- 
engagement is  abdomen  to  abdomen. 


Fig.  257. — Presentation  of  the  thorax,     a,  transformation  into  vertex ; 
b,  transformation  into  breech. 

Presentation  of  the  thorax. — In  the  different  presentations 
that  we  have  already  studied,  the  accouchement  may  terminate  in 
two  ways : 


210 


Median  ism  of  Accouchement. — Fcetal  Phenomena. 


1.  By  transformation  of  one  presentation  into  another,  vertex  into 
brow  and  into  face,  breech  into  vertex,  etc.,  there  is  produced  a 
veritable  mutation. 

2.  By  a  mechanism  in  six  successive  stages. 


/rcr 


FlGS.  258  to  261. — Spontaneous  evolution.     Different  attitudes  of  the  foetus  during 
the  successive  disengagement  of  the  trunk  (Spiegelberg). 

In  presentation  of  the  thorax,  the  accouchement,  when  it  takes 
place,  is  terminated :  1.  By  transformation  of  the  presentation, 
called  spontaneous  version.  2.  By  a  mechanism  analogous  to  that  of 
the  other  presentations,  here  designated  as  spontaneous  evolution. 

Spontaneous  version  and  evolution  are  terms  usually  reserved 
for  presentations  of  the  shoulder,  but  they  imply  no  special  character. 
The  only  peculiarity  of  presentations  of  the  thorax  is,  that,  in  the 
usual  conditions,  they  do  not  terminate  in  spontaneous  accouche- 
ment. It  is  always  necessary  to  interfere  when  the  foetus  presents 
by  the  thorax.     Spontaneous  version  and  evolution  should,  then,  be 


Mechanism  of  Accouchement, — Foetal  Phenomena. 


211 


considered  .-is  exceptions,  that  we  should  know,  nevertheless,  as  they 
confirm  the  general  laws  of  the  mechanism  of  accouchement.    Their 

interest  is  consequently  more  theoretical  than  practical. 


Fig.  262. — Spontaneous  evolution.     Successive  disengagement  of  the  trunk. 


Fin.  263.  — Schema  of  disengagement  of  the  trunk  in  spontaneous  evolution. 

1.  Spontaneous  version  (or  mutation  of  the  ^presentation). — Under 
the  influence  of  uterine  contraction,  and  before  engagement  of  the 
foetal  part,  the  thorax  is  seen  to  draw  away  from  the  superior  strait 


212 


Mechanism  of  Accouchement. — Foetal  Phenomena, 


and  be  replaced  at  that  point  by  the  head  or  the  breech.  The  pre- 
sentation of  the  thorax  is  then  transformed  in  the  first  case  into  a 
vertex  presentation,  spontaneous  cephalic  version;  in  the  second 
case  into  a  breech  presentation,  spontaneous  pelvic  version.  Though 
this  change  is  easier  during  integrity  of  the  bag  of  waters  it  may 
take  place  after  its  rupture.  The  subsequent  accouchement  of  the 
breech  or  the  head  follows  the  usual  rules. 


Fig.  264. — Expulsion  of  the  foetus  folded  in  two  (conduplicato 
corpore)  (Kleimvachter). 

2.  Spontaneous  evolution  (or  normal  mechanism  of  the  accouche- 
ment).—  The  back  and  the  sternum  constitute  such  rare  varieties  of 
presentations  of  the  thorax  that  they  may  be  neglected  in  the  point 
of  view  of  spontaneous  evolution,  so  it  is  only  the  presentation  of 
the  shoulder  (right  or  left)  that  I  shall  discuss  here. 

I  shall  take  as  the  type  a  presentation  of  the  right  shoulder  in 
E  A  I  T. 

1.  Diminution. — The  diminution  is  made  in  proportion  to  the  en- 
gagement. The  adherence  of  the  upper  limb  to  the  trunk  becomes 
more  and  more  intimate  (unless  it  is  drawn  down  and  the  head  is 
at  the  vulva)  and  the  thorax  and  the  abdomen  are  successively 
molded  to  traverse  the  parturient  canal. 


Mechanism  of  Accouchement. — Fcetal  Phenomena.  213 

2.  Engagement. — The  Bhoulder,  which  forms  the  culminating  pari 
of  the  presentation,  descends  by  following  very  nearly  the  axis  of 
the  parturienl  canal.  The  shoulder  first,  then  the  thorax  and  neck 
folded  together,  advance  progressively  and  with  difficulty.  This 
movement  of  descent  is  arrested  at  the  moment  when  the  head 
arrives  in  contact  with  the  upper  part  of  the  pubes. 

3.  I  ate  ninl  rotation. — As  in  all  other  presentations,  the  fcetal  part, 
transverse  at  the  superior  strait,  is  obliquely  placed  in  the  exca- 
vation, and  antero-posteriorly  at  the  median  strait.  The  head  is 
placed  forward  in  such  a  way  that  the  neck  measures  the  height  of 
the  puhes.  The  trunk  is  directed  backward.  This  situation  of  the 
feetus  is  indispensable  for  disengagement. 

4.  Disengagement  of  the  trunk. — The  fourth  stage  is  the  most  interest- 
ing and  at  the  same  time  the  most  difficult  part  of  spontaneous 
evolution.  The  foetus  first  becomes  indented  (Fig.  258),  the  inden- 
tation is  accentuated  (Fig.  259),  the  feetus  is  soon  folded  on  itself 
(Fig.  260),  and  finally  the  breech  continuing  to  descend,  while  the 
bead  remains  immobile,  the  exit  of  the  trunk  is  complete  (Fig.  261). 

5.  6. — External  rotation  and  disengagement  of  the  head  take  place 
identically  as  in  presentation  of  the  breech. 

Mechanism  in  each  variety  of  presentation  and  of  position. — What- 
ever may  be  the  variety  of  the  presentation,  right  or  left  shoulder, 
and  of  postion,  R  A  I  T  or  L  A  I  T,  the  mechanism  is  analogous, 
rotation  of  the  head  and  neck  forward  and  disengagement  by  an 
unrolling  of  the  trunk  (Figs.  262  and  263). 

Irregularities  of  mechanism. — The  mechanism  of  spontaneous  evo- 
lution being  relatively  rare,  the  anomalies  are  still  more  rare.  A 
single  one  merits  mention,  the  exit  of  the  feetus  folded  in  two  parts 
as  in  presentation  of  the  abdomen  (Fig.  264). 

Spontaneous  version,  permitting  the  birth  of  a  living  child,  only 
occurs  in  about  one  case  out  of  forty.  This  is  to  say  that  one  should 
always  interfere  in  these  presentations.  We  shall  see  how  in  an 
subsequent  chapter. 

Presentation  of  the  abdomen. — "When  a  child  presents  by 
the  abdomen,  whatever  the  variety  (lumbar  regions,  right  or  left 
flank,  umbilicus),  spontaneous  accouchement  at  term  is  impossible. 
However,  with  particularly  supple  foetus,  already  dead  some  time, 
or  before  term,  the  foetus  may  make  an  exit  bent  double  (Fig.  264). 
In  presentation  of  the  abdomen  the  indications  for  interference  are 
absolute. 


214  Influence  of  Accouchement  on  Mother  and  Child. 


CHAPTER  XI 


INFLUENCE  OF  ACCOUCHEMENT  ON  THE 
MOTHER  AND  ON  THE  CHILD. 

Influence  of  accouchement  on  the  mother. — Nervous  sys- 
tem.— Thereoften  exists  a  marked  state  of  restlessness  and  anxiety, 
sometimes  a  veritable  passing  delirium  and  without  importance. 
There  are  frequent  cramps  in  the  lower  limbs,  due  to  the  compres- 
sion of  the  obdurator  nerve  and  of  the  great  sciatic. 

Calorification. — Elevation  of  the  temperature  some  tenths  of  a 
degree,  but  no  fever  in  the  normal  state. 

Respiration. — Accelerated,  interrupted  by  cries  and  complaints. 

Digestion. — Frequent  vomiting  during  labor.  It  appears  that  the 
uterine  contractions  cause  those  of  the  stomach.  Sometimes  labor 
commences  by  an  indigestion.  As  soon  as  the  pains  become  intense 
the  woman  feels  a  disgust  for  food  and  drink,  and  it  is  better  to 
exclude  food,  for  the  ingestion  of  liquids  or  solids  often  causes 
vomiting. 


FlG.  265. — Formation  of  the  sero-sanguineous  swelling. 

Influence  of  accouchement  on  the  child. — The  influence 
of  the  uterine  contraction  on  the  fcetal  circulation  has  already  been 
explained.  The  most  interesting  influence  on  the  foetus  consist  of 
the  different  deformations  that  accouchement  produces,  which  have 
been  designated  as  plastic  phenomena.  These  plastic  phenomena 
are  of  two  kinds,  one  causing  a  deformation  of  the  soft  parts  and 
producing  a  sero-sanguineous  protuberance,  the  other  addressed  to 
the  skeleton  and  characterized  by  an  osseous  deformation. 


Influence  of  Accouchement  on  Mother  and  Child. 


215 


1.  Sero-sanguineous  protuberance. — On  the  f oetaJ  pari  lefl  bare  by 
the  dilatation  of  the  cervix  there  is  formed,  in  the  subcutaneous 
cellular  tissue,  a  Bero-sanguineous  infiltration  (caput  succedaneum). 
The  skin  at  this  point  presents  a  color  sometimes  red,  more  often 
violaceous  and  quite  clearly  circumscribed.  This,  added  to  the 
doughiness  of  the  subjacent  tissues,  permits  an  easy  diagnosis  after 
birth.  Sometimes  there  exists  congestion  of  the  periosteum  and 
also  of  the  pia  mater,  and  of  the  brain  if  it  relates  to  the  head.. 


FlG.  266. — Vertex;  different  sites  of  the  sero-sanguineous  swelling  according 
to  the  position. 

The  mechanism  by  which  this  sero-sanguineous  swelling  is  pro- 
duced is  only  that  of  cupping  (Fig.  265).  The  situation  of  the 
swelling  naturally  varies  with  the  presentation  (Fig.  266).  The 
sero-sanguineous  swelling  has  only  the  inconvenience  of  deforming 
the  foetal  region  on  which  it  is  situated.  It  disappears  in  three  or 
four  days  and  demands  no  special  treatment. 

2.  Osseous  deformations  of  the  festal  head  caused  by  the  over-laping 
of  the  bones.  The  general  result  of  this  over-riding  is  a  change  in 
the  configuration  of  the  head  as  indicated  in  the  subjoined  figures. 


Fig.  267. — Form  of  the  head  after  ex-  Fin.  268.—  Form  of  the  head  after  ex- 
pulsion in  lefl  or  right  occipito-anterior  pulsion  in  left  or  right  occipito-posterior 
vertex  presentation  (Tarnier).  vertex  presentation  (Tarnier). 


216 


Influence  of  Accouchement  on  Mother  and  Child. 


Fig.  269. — Form  of  the  head  after  ex-       Fig.  27c — Form  of  the  head  after  ex- 
pulsion in  brow  presentation  (TarnierJ.      pulsion  in  face  presentation  (Saxinger). 


Promontory. 


Pubes. 


Fig.  271. — Deformation  of  the  head  expelled  last. 

Causes  of  accouchement. — We  find  in  the  production  of 
accouchement  two  causes,  efficient  and  determinate. 

1.  Efficient  causes. — The  foetus  is  essentially  passive  during  ac- 
couchement and  the  efficient  cause  of  the  birth  of  the  child  is 
uterine  contraction  aided  by  that  of  the  abdomen.  There  have  been 
some  cases  of  spontaneous  accouchement  observed  after  the  death 
of  the  mother,  testifying  simply  to  the  persistence  of  uterine  con- 
traction after  the  cessation  of  life. 

2.  Determinate  causes. — Why  does  the  uterus  enter  into  contraction 
at  the  end  of  nine  months,  the  normal  term  of  pregnancy  ?  The 
fcetus,  the  membranes,  and  the  uterus,  have  been  in  turn  brought 
forward  as  causes. 

a.  Foetus. — All  impediments  of  fcetal  physiology  have  been  given 
as  determining  accouchement.  Opinions  formerly  varied  much  on 
the  source  of  these  obstructions.  I  cite  the  principal  ones :  Dis- 
tension  of  the  intestine  by  meconium  and  of  the  bladder  by  the 
urine ;  insufficiency  of  circulation  by  progressive  narrowing  of  the 
foramen  ovale ;  obstruction  to  fcetal  movements  by  the  uterus  be 
coming  relatively  too  small. 

It  is  possible  that  accouchement  may  have  the  fortunate  effect  of 
affording  a  remedy  for  these  obstructions,  but  it  cannot  be  con- 
ceived that  they  are  capable  of  becoming  the  determinate  cause  of 
labor. 


Infltten.ee  of  Accouchement  on  Mother  and  Child.  217 

b.  Membranes. — At  term  the  degenerated  decidua  is  separated 

from  the  uterus  to  quite  a  great  extent.  Thus  the  ovum  forms  a 
foreign  body  in  the  uterus  and  produces  labor  (Simpson).  It  is 
certain  that  every  foreign  body  in  contact  with  the  internal  surface 
of  the  uterus  causes  more  or  less  severe  contractions,  but  it  is 
difficult  to  understand  why,  the  separation  of  the  ovum  from  the 
uterus  being  progressively  made  during  the  last  three  months  anil 
the  detachment  proceeding  from  the  internal  orifice  toward  the 
fundus,  labor  occurs  exactly  at  the  end  of  nine  months  and  not  at  a 
more  advanced  period.  Besides  in  pathological  adhesions  of  the 
membranes  labor  would  never  occur. 

c.  Uterus. — The  derminate  cause  has  been  sought,  either  in  the 
circulation  of  the  uterus  or  in  the  muscular  tissue  of  the  organ. 

Circulation. — Two  theories  : 

Theory  of  uterine  asphyxia. — Like  all  the  muscles  of  organic  life, 
the  uterus  is  very  sensitive  to  the  action  of  carbonic  acid ;  now  the 
stasis  in  the  last  period  of  pregnancy  favors  the  accumulation  of 
this  gas,  and  to  this  Brown- Sequard  attributes  the  production  of 
labor.  The  principle  of  this  explanation  is  true,  but,  this  local 
asphyxia  being  progressive,  it  is  difficult  to  comprehend  how  it 
becomes,  just  at  normal  term,  sufficient  to  produce  accouchement. 

Theory  of  the  tenth  menstrual  epoch. — Every  month  during  preg- 
nancy, at  the  time  corresponding  to  the  menstrual  epoch,  is  produced 
a  genital  congestion  which  favors  uterine  contraction  and  exposes 
the  woman  to  abortion.  Tyler  Smith  advances  the  theory  that  the 
tenth  menstrual  period  becomes  the  cause  of  labor.  This  theory 
cannot  be  admitted,  for  often  the  time  of  accouchement  does  not 
coincide  with  the  tenth  menstrual  period. 

Musculo. r  fibre. — Two  theories ; 

Theory  of  maturity  of  the  uterine  fibre. — Chaussier  believes  that 
the  uterine  fibres  attain  a  maturity  which  renders  them  apt  to 
contract  energetically  at  the  end  of  nine  months.  This  is  pure 
hypothesis. 

Theory  of  the  irritability  of  the  uterine  fibres. — Uterine  irritability, 
latent  during  the  course  of  pregnancy  when  it  is  only  revealed  by 
slight  contractions,  is  manifested  in  all  its  energy  at  the  term  of 
gestation,  awakened  either  by  distention  of  the  body  of  the  uterus 
or  by  that  of  the  cervix. 

a.  Distention  of  the  body  of  tlie  uterus. — This  theory  sustains  that 
the  uterus,  like  the  rectum  and  the  bladder,  will  contract  when  it  is 
distended  to  the  maximum  and  that  accouchement  thus  takes  place 
by  a  mechanism  analogous  to  defecation  and  to  micturition.  Se- 
ductive at  first  glance,  this  is  not  satisfactory  on  attentive  examin- 
ation.    For  if  accouchement  took  place  by  a  similar  mechanism, 


218  Influence  of  Accouchement  on  Mother  and  Child. 

the  moment  of  its  defecation  might  vary,  as  the  periods  of  mictu- 
rition and  defecation  vary  in  different  women,  and  take  place  at  the 
seventh,  eighth,  ninth  or  tenth  month.  Besides  the  same  woman 
may  be  delivered  at  term  of  a  single  fcetus  or  of  two,  and  in  the 
second  case  the  uterus  is  much  more  distended  than  in  the  first. 
Finally  in  extra-uterine  pregnancy  a  pseudo  labor  follows  at  term. 

b.  Distention  of  the  cervix. — According  to  Levret,  the  cervix  becom- 
ing effaced  in  the  latter  part  of  pregnancy,  uterine  contractions 
follow.  But  this  theory  cannot  be  admitted  for  often  the  cervix  is 
only  effaced  during  labor. 

In  resume,  in  all  the  preceding  theories,  we  find  influences  which 
explain  the  appearance  of  labor  but  none  of  them  explain  why  labor 
is  regularly  produced  at  the  end  of  the  ninth  month. 

Diagnosis  of  accouchement. — When  a  physician  is  called 
attend  to  a  woman  normally  pregnant  and  suffering  intermittent 
abdominal  pains,  he  should  always  seek  the  solution  of  the  following 
questions : 

I.  Is  this  woman  in  labor? 

II.  What  is  the  presentation  and  the  position  of  the  fcetus  ? 

I.  Diagnosis  of  ledjor. — In  a  practical  point  of  view  it  is  the  immi- 
nence of  fcetal  expulsion  that  we  seek.  We  wish  to  know  how  soon 
the  woman  will  be  delivered  and  whether  to  remain  or  not,  to  assist 
at  the  moment  of  expulsion.  Now  there  is  no  diagnostic  point  that 
is  more  exposed  to  error  than  this.  An  experienced  accoucheur 
may  decide  that  the  woman  will  not  be  delivered  soon  and  yet  in  an 
hour  the  child  may  be  born.  Again,  he  may  assure  the  woman  that 
she  will  be  delivered  in  a  few  hours  and  yet  at  the  end  of  twelve  or 
twenty-four  hours  the  accouchement  has  not  advanced,  and  labor 
may  even  be  postponed  for  two  weeks  or  a  month.  These  inevitable 
errors  are  due : 

1.  To  the  difficulty  of  exactly  recognizing  the  beginning  of  labor. 

2.  To  the  rapidity,  sometimes  excessive,  of  the  accouchement. 

3.  To  the  arrest  and  retrocession  of  labor. 

Labor,  according  to  some,  commences  with  painful  uterine  con- 
traction, but  certain  women  are  delivered  without  suffering,  while 
others  suffer  all  through  the  last  month  of  pregnancy.  According  to 
others,  who  make  labor  synonymous  with  the  opening  of  the  cervix 
(effacement  and  dilatation),  it  begins  with  effacement  of  the  cervix. 
This  is  certainly  a  valuable  element,  but  in  which  we  cannot  fully 
confide,  for  some  women  have  the  cervix  effaced  in  latter  part  of 
pregnancy  without  being  in  labor. 

Labor,  in  fact,  is  the  assemblage  of  acute  modifications  which  are 
produced  in  the  maternal  organism  to  cause  with  a  brief  delay  the 
birth  of  the  child.     It  is  necessary  not  to  remove  from  the  tern]  labor 


Influena  of  Accouchement  on  Mother  and  Child.  219 

its  signification  of  approaching  expulsion,  as  without  this  il  I 
all  practical  interest  and  falls  into  theoretical  domain. 

Et  is  important  to  seek  the  elements  on  which  we  can  1  a.-e  our 
diagnosis  of  labor.     They  arc  three  in  number: 

Painful  uterine  contraction. 

Opening  of  the  cervix. 

The  show. 

Uterine  contractions  only  indicate  labor  when  they  are  markedly 
painful.  It  is  especially  necessary  not  to  confound  with  them  other 
pains  (vesical,'  intestinal,  nephritic,  hepatic  colic)  which  may  occur 
in  the  abdomen. 

The  opening  of  the  cervix  comprises  effacement  and  dilatation  of 
the  external  orifice.  Now,  when  after  effacement  the  dilatation  has 
attained  two  fingers'  breadth,  or  more,  the  diagnosis  of  labor  is  no 
longer  doubtful.  Two  successive  examinations  with  a  quarter  of 
an  hour  interval  will  be  sufficient  to  show  if  the  opening  is  progres- 
sive or  stationary.  If  progressive,  the  diagnosis  of  labor  can  be 
made ;  if  stationary,  the  diagnosis  should  be  reserved.  When 
several  examinations  of  the  cervix  reveal  no  modification,  we  can 
conclude  in  cases  where  the  uterine  pains  are  mil  or  little  energetic, 
and  where  the  vagina  presents  but  little  show,  the  absence  or  arrest 
of  labor. 

The  show,  the  flow  of  which  indicates  both  the  opening  of  the 
cervix  uteri  and  the  energy  of  the  uterine  contractions,  is  also  a 
good  sign  of  labor. 

When  these  three  signs  are  present  the  diagnosis  of  labor  is  easy. 
But  one  of  them  may  be  wanting;  for  example,  the  uterine  con- 
traction remaining  painless  or  the  cervical  dilatation  not  progres- 
sing. In  such  cases  we  can  still  make  a  diagnosis  of  labor  when 
the  two  existing  signs  are  clear  and  characteristic.  Finally  two  of 
these  signs  may  be  wanting,  and  a  single  one  permit  us  to  establish 
the  diagnosis  of  labor ;  for  example,  the  progressive  dilatation  of  the 
cervix  with  the  absence  of  pain  or  of  the  show.  We  can  then  say 
a  woman  is  in  labor  when  there  is  found  : 

1.  Contractions  of  the  uterus,  markedly  painful. 

2.  A  progressive  opening  of  the  cervix  (effacement  or  beginning 
dilatation),  or  with  a  cervix  effaced  and  dilated  at  least  to  an  extent 
equal  to  two  fingers'  breadth. 

3.  A  sufficiently  abundant  and  continued  show. 

II.  Diagnosis  of  the  presentations  and  i><>sitio)is. — The  diagnosis  of 
the  presentation  and  position  of  the  fcetus  is  made  with  the  aid  of 
palpation,  of  auscultation  and  of  digital  examination.  Interrogation 
and  inspection  furnish  us  no  knowledge  of  importance  on  the.-e 
points. 


220  Influence  of  Accouchement  on  Mother  and  Child. 

We  have  already  seen,  apropos  of  pregnancy,  how  palpation  and 
auscultation  may  lead  to  the  diagnosis  of  the  foetal  presentations 
and  positions.  We  have  also  seen  what  information  may  be  fur- 
nished by  vaginal  touch  before  the  opening  of  the  cervix,  there  only 
remains  to  study  digital  examination  after  the  opening  of  the  cervix. 

Vaginal  touch  after  the  opening  of  the  cervix. 

1.  Vertex. 

a.  Presentation. — Foetal  part,  hard,  rounded,  even.  Sutures  and 
fontanelles  —  the  lambda  is  nearer  to  the  genital  axis  than  the 
bregma.  In  the  opposite  condition,  the  presentation  is  that  of  the 
brow  or  tending  toward  it. 

h.  Position. — The  position  will  be  indicated  by  the  sagittal  suture, 
the  lambda  indicating  the  situation  of  the  occiput. 

c.  Causes  of  error. 

1.  Vices  of  ossification. — The  accessory  fontanelle  has  only  two 
sutures,  terminating  in  it,  and  will  not  be  confounded  with  the 
lambda  which  has  three,  nor  with  the  bregma  which  has  four. 

2.  The  asteric  fontanelle,  in  cases  of  inclination  of  the  head  may 
be  mistaken  for  the  lambda.  The  asteric  fontanelle  will  be  recog- 
nized by  the  projection  of  the  asterion  and  the  vicinity  of  the  ear. 

3.  If  a  sero-sanguineous  swelling  prevents  the  perception  of  the- 
details  of  the  head,  the  ear  will  be  sought  and  the  direction  of  the 
occiput  ascertained  by  exploring  its  pavilion. 

4.  In  cases  of  cephalic  malformation,  manual  examination  will 
permit  us  to  reach  the  face  and  even  the  trunk  of  the  child. 

2.  Face. 

a.  Presentation. — Special  sensations  furnished  by  the  mouth,  the 
nose  and  the  eyes. 

h.  Position. — The  exploration  of  the  preceding  organs,  when  the 
chin  cannot  be  reached,  allows  determination  of  the  position. 

c.  Causes  of  error. 

1.  Confusion  with  the  buttocks  may  take  place  when  the  cheeks 
are  considerably  swollen.  Distinction  by  the  presence  of  the  facial 
organs  around  the  groove. 

2.  Confusion  of  the  mouth  with  the  anus. — In  the  mouth  are  felt 
the  maxillary  alveoli,  the  tongue  and  the  frsenurn  of  the  tongue. 
From  the  anus  the  finger  returns  soiled  with  meconium. 

3.  Brow. 

a.  Presentation. — Chaiacters  analogous  to  those  of  the  vertex  (but 
with  the  lambda  accessible  with  difficulty  or  not  at  all).  The 
orbital  arches,  the  eyes,  and  even  the  nose,  may  be  reached. 

h.  Position. — After  exploration  of  the  bregma  and  the  lambda  or 
of  the  height  of  the  face  the  situation  of  the  head  can  be  diagnosed. 

c.  Causes  of  error. — The  same  as  for  a  vertex  presentation. 


Influence  <>!'  A  crunr  heme  lit  on  Mother  and  Child.  221 

4.  Breeeh. 

a.  Presentation. — Complete  breech — buttocks,  feet,  sacral  crest, 
>\,  anus,  external  genital  organs.  Incomplete  breech  -same 
characters  minus  the  feet.  Variety  of  the  knees — two  small  cyl- 
inders, constituted  by  the  two  segments  of  the  lower  limb,  meeting 
at  an  angle.  Variety  of  the  feet — only  the  feet  can  be  felt.  Manual 
touch  alone  allows  the  breech  to  be  attained. 

h.  Position. — Whatever  the  variety  of  the  presentation,  the  po- 
sition can  be  clearly  determined  only  when  the  anus  and  the 
coccyx  or  the  sacral  crest  can  be  felt. 

c.  Causes  of  error. — I  shall  not  return  to  those  mentioned  apropos 
of  the  face.  Knees — confusion  with  the  elbow,  differentation  by 
exploration  of  the  contiguous  parts  in  difficult  cases.  Foot — con- 
fusion with  a  hand,  fingers  larger  than  toes,  thumb  clearly  separated 
from  the  fingers.  In  the  foot,  the  contiguous  malleoli  are  quite 
different  from  the  wrist. 

5.  Thorax. 

a.  Presentation. — Characteristic  costal  region. 

Dorsal  variety — projections  of  the  spinal  apophyses. 

Sternal  variety — sternal  quadrilateral  interrupting  the  costal 
region. 

Shoulder  variety — projection  of  the  shoulder  and  of  the  acromion, 
scapula  on  one  side,  clavicle  on  the  other  (the  diagnosis  of  right  and 
left  shoulder  will  be  made  with  that  of  the  position). 

h.  Position. — In  the  dorsal  and  sternal  varieties,  the  position  can 
scarcely  be  recognized  except  by  manual  touch  or  by  the  aid  of  pal- 
pation, but  most  often  this  diagnosis  is  to  be  made  in  the  shoulder 
variety.  To  recognize  the  presentation  of  the  shoulder  and  its  po- 
sition we  have  recourse  to  three  elements,  of  which  two  should  be 
clearly  determined.  Presentation  of  the  shoulder  is  like  a  triangle, 
of  which  two  angles  being  known  we  can  determine  the  third,  and 
at  the  same  time  all  the  triangle. 

These  three  elements  are  : 

Head.\ /Back. 


Shoulder. 

When  the  situation  of  the  back  and  of  the  head  is  known,  the 
shoulder  which  presents  and  the  position  of  the  foetus  can  be  de- 
termined. When  the  situation  of  the  back  and  the  shoulder  which 
presents  are  known,  the  situation  of  the  head  can  be  determined. 
When  the  situation  of  the  head  and  the  shoulder  which  presents  are 
known,  the  position  of  the  back  can  be  determinefi.  It  is  evident 
that  palpation  will  be  a  great  help  in  the  determination  of  these  two 
element*. 


222  Influence  of  Accouchement  on  Mother  and  Child. 

c.  Causes  of  error. 

Procidence  of  a  foot  may  lead  to  a  confusion  with  a  presentation 
of  the  breech.  Attentive  exploration  will  avoid  this  confusion. 
Procidence  of  a  hand  in  another  presentation  than  that  of  the 
shoulder  may  give  rise  to  doubts  only  removed  by  a  detailed  exami- 
nation. 

6.  Abdomen. 

a.  Presentation. — Characteristic  softness  of  the  abdomen. 
Umbilical  variety — insertion  of  the  umbilical  cord. 

Variety  of  the  flanks — contiguity  of  the  costal  region  and  of  the 
iliac  crest. 

Variety  of  the  lumbar  regions — resisting  part,  with  the  pro- 
jections of  the  spinal  apophyses,  dividing  the  soft  tissues. 

b.  Position. — The  diagnosis  will  be  made  in  a  manner  analogous 
to  that  indicated  for  the  thorax.  The  situation  of  the  back  and 
head  will  be  determined  by  palpation  and  manual  touch. 

c.  Causes  of  error. — The  softness  of  the  abdominal  wall  may 
create  confusion  with  a  thick  bag  of  waters.  The  insertion  of  the 
cord  and,  at  need,  manual  touch  will  avoid  mistakes. 

Duration  of  accouchement. — The  duration  of  accouchement 
is  quite  variable  ;  however,  it  can,  outside  of  causes  of  dystocia,  be 
fixed  at  twelve  hours  in  the  primipara  and  at  six  hours  in  the  multi- 
para. The  period  of  the  opening  of  the  cervix  occupies  about  five- 
sixths  of  this  time  and  the  expulsion  one-sixth. 

Previous  deliveries  give  information  on  the  rapidity  for,  all  things 
being  equal,  the  duration  of  accouchement  remains  proportionately 
equal  in  the  same  woman.  Heredity  also  plays  an  interesting  part, 
as  the  study  of  certain  number  of  cases  permits  the  formulation  of 
the  following :  The  duration  of  the  accouchement  is,  in  the  absence 
of  all  causes  of  dystocia,  analogous  to  that  of  the  accouchement  of 
the  mother  or  of  the  paternal  grandmother,  according  as  the 
physical  resemblance  of  the  woman  relates  to  her  mother  or  to  her 
father.  Accouchement  in  obese  females  is  generally  longer  than 
normal. 

The  question  of  the  presumable  duration  of  the  accouchement  is 
one  of  those  so  often  asked  of  a  physician  during  labor.  The 
responses  should  be  very  circumspect,  for  the  duration  is  exceed- 
ingly variable  and  errors  are  frequent. 

Prognosis  of  accouchement. — The  prognosis  of  accouche- 
ment for  the  mother  and  for  the  child  depends  upon  such  a  multi- 
tude of  conditions  that  it  will  be  impossible  to  trace  here  more  than 
a  bare  outline. 


Influence  oj  Accouchement  on  Mother  and  Child.  228 

A.  Mother. — The  prognosis  for  the  mother  depends : 

1.  Upon  the  presentation  and  the  position  of  the  child.  The  more 
frequenl  ;i  position,  the  better  i.-.  its  prognosis.  With  regard  to 
tin   piesentations  of  the  cephalic  ovoid  the  anterior  positions  are 

more  favorable  than  the  posterior,  on  account  of  greater  facility  of 
internal  rotation. 

2.  Upon  peculiarities  of  pregnancy  or  of  accouchement.  Twin 
pregnancy;  hydramnios;  viscous  insertion  of  the  placenta;  lacer- 
ation of  the  cervix,  perinfflum,  etc.,  all  complications,  darken  the 
prognosis. 

3.  The  place  in  which  the  woman  is  delivered.  Formerly,  before 
the  antiseptic  period,  the  hospital  was  a  deplorable  place  for  ac- 
couchement. To-day  puerperal  mortality  is  less  in  the  hospital 
than  in  the  private  houses. 

4.  Upon  the  person  who  assists  at  delivery.  Numerous  compli- 
cations result  simply  from  violation  of  antisepsis,  from  ignorance, 
and  from  too  great  haste  in  interventions. 

B.  Child. — The  prognosis  for  the  child  depends  : 

1.  Upon  the  presentation  and  the  position. 

a.  Foetal  mortality  according  to  the  different  presentations  (out- 
side all  causes  of  dystosia,  other  than  that  caused  by  the  presen- 
tation). 

CEPHALIC  OVOID.  CORMIC  OVOID. 

1.  Vertex  Tfff  1.  Breech  T\, 

2.  Face  &  2.  Thorax  \ 

3.  Brow  \  3.  Abdomen  ? 

For  each  ovoid  the  order  of  increasing  gravity  is  the  following : 
Presentation  of  the  large  extremity. 
Presentation  of  the  small  extremity. 
Presentation  of  the  intermediate  part. 

b.  Prognosis  according  to  the  variety  of  presentation  and  of  po- 
sition. 

Vertex — The  occipitoanterior  positions  are  more  grave  than  the 
anterior. 

Face,  Brow — The  mento-posterior  positions  are  also  more  grave 
than  the  anterior. 

Breech— The  incomplete  breech,  variety  of  the  thighs,  is  of  worse 
prognosis  than  the  other  varieties. 

Thorax,  Abdoinen — The  dorso-anterior  positions  are  more  favor- 
able, when  version  is  necessary,  and  the  posterior,  on  the 
contrary  when  embryotomy  is  required. 

2.  Upon  the  volume  and  upon  the  number  of  foetuses.  The 
greater  the  volume  of  the  child  the  more  the  chance>  of  dvstocia 


224 


Management  of  Accouchement. 


increase.     The  more  foetuses  in  the  uterine  cavity,  the  more  unfa- 
vorable becomes  the  prognosis  for  each  one  of  them. 

3.  Upon  the  conformation  of  the  woman. 

4.  Upon  the  complications  of  pregnancy  and  of  accouchement. 

5.  Upon  the  person  who  assists  at  delivery  as  for  the  mother. 


CHAPTER  XII. 


MANAGEMENT  OF  ACCOUCHEMENT. 

1.  Management  of  accouchement  in  general.  —  A.  Pre- 
paratory. — All  useless  textures  should  be  removed  from  the  partu^ 
rient  chamber.  The  room  should  be  heated  to  18°  C.  and  maintained 
at  that  temperature  to  avoid  the  chilling  to  which  the  woman  is 
exposed. 


Fig.  272. — Bed  prepared  for  accouchement. 

In  preparing  the  bed  for  an  expected  accouchement  there  is  placed 
over  the  sheet  covering  the  mattress  (Fig.  272)  an  impermeable  cloth 
(oil-cloth  or  rubber)  having  the  width  of  the  bed  and  a  length  of 
about  one  metre  and  a  half.  Above  this  is  a  sheet  folded  double, 
then  another  impermeable  cloth  and,  finally,  a  sheet  folded  double 
as  before.  These  sheets  are  fixed  to  the  mattress  by  safety  pins. 
The  first  portion,  including  the  first  impermeable  cloth,  is  to  be  re- 
moved after  delivery ;  the  second  is  to  be  left  during  the  post-partum. 

A  vaginal  injector  is  indispensable.  The  most  simple  is  the  best. 
I  use  the  injector  represented  by  Fig.  273.  A  bed-pan  is  equally 
indispensable. 

Absorbent  cotton  should  be  used  in  place  of  a  sponge,  and  to 
apply  to  the  vulva  during  the  post-partum. 

The  armamentarium  of  the  obstetrician  should  consist  of  forceps, 


Management  of  Accouchement. 


OQK 


uterine  .sound,  needles  and  sutures,  ordinary  scissors,  two  bistouries, 
one  pointed  the  other  blunt,  six  haemostatic  forceps,  obstetrical 
stethoscope,  a  speculum  and  a  hypodermic  Byringe.  It  will  be  better 
to  add  a  bottle  of  chloroform  and  one  of  a  solution  ol  ergotine,  two 
rolls  of  iodoform  gauze,  two  vulsela  and  a  dressing  forceps. 


Fig.  273. — Vaginal  irrigator  of  nickeled  metal. 

B.  Management  of  accouchement. 

Period  of  dilatation  of  the  cervix. — At  the  beginning  of  labor  an 
enema  should  be  given  to  have  the  rectum  empty  during  the  period 
of  expulsion.  Every  three  or  four  hours  the  vulva  should  be  washed 
and  this  should  be  followed  by  a  vaginal  injection  (bichloride  of 
mercury,  1-4000),  taking  care  during  the  first  injection  to  make  as 
complete  lavage  as  possible  by  rubbing  the  vaginal  and  cervical 
walls  with  the  fingers,  or  better,  by  using  the  finger  irrigator  (Fin. 
274).  This  genital  toilet  should  be  made  by  the  physician  for  on 
the  asepsis  of  the  genital  organs  depends  the  normal  progress  of 
the  post-partum. 


Fig.  274. — Finger  irrigator. 


The  distention  of  the  bladder  will  be  watched,  and  when  mictu- 
rition is  impossible  catheterism  will  be  necessary. 


226 


Management  of  Accouchement. 


During  this  period  of  dilatation  of  the  cervix  the  patient  may  move 
about  at  will  (except  in  certain  special  conditions  which  necessitate 
a  horizontal  decubitus). 

Period  of  expulsion. — During  the  close  of  the  period  of  dilatation, 
and  especially  during  the  period  of  expulsion,  it  is  important  to 
auscultate  the  sounds  of  the  foetal  heart,  to  be  in  readiness  to  in- 
tervene if  their  exaggerated  frequence  or  their  slowness  causes  fear 
for  the  life  of  the  child.  From  the  moment  of  complete  dilatation 
the  woman  should  remain  in  bed,  in  the  position  that  is  agreeable 
to  her. 

As  soon  as  the  head  appears  at  the  vulva  (primipara)  or  in  its 
vicinity  (multipara),  the  woman  will  be  placed  in  the  lateral  position 
or  the  dorsal  position.  The  buttocks  are  raised  (Fig.  275)  the  thighs 
flexed  and  separated.  Two  persons  give  each  a  hand  to  the  patient 
to  afford  a  support  in  her  efforts.  The  accoucheur  sustains  the 
perimeum  and  watches  the  exit  of  the  child,  which  should  be  as 
slow  as  possible.  The  head,  or  in  a  general  manner  the  icetal  part, 
should  be  brought  through  the  vulvar  orifice  in  the  interval  between 
two  contractions.  At  this  moment  the  patient  should  be  instructed 
not  to  bear  down,  in  spite  of  the  imperious  need  she  feels,  or  to 
bear  down  in  the  interval  of  the  uterine  contractions 


Fig.  275. — Buttocks  raised  to  facilitate  expulsion.     L,book;    A,  sheet  wrapped 
round  the  book  and  corresponding  by  its  free  end  with  the  feet  of  the  woman. 

Generally  at  the  moment  the  anus  dilates  the  woman  feels  the 
need  of  defecation  and  sometimes  demands  permission  to  get  up. 
The  physician  should  refuse  this,  explaining  at  the  same  time  that 
it  is  only  a  false  call  of  nature  and  the  result  would  be  nul. 

Ligature  of  the  cord  and  delivery  of  the  appendages. — After  the  birth 
of  the  child  it  is  necessary  to  tie  and  to  cut  the  cord  and  to  proceed 
to  the  delivery  of  the  after-birth.  The  management  of  the  latter  will 
be  considered  in  the  study  of  the  last  stage  of  accouchement ;  here 
we  will  simply  attend  to  the  ligature  of  the  cord  and  the  care  con- 
secutive to  delivery. 

To  avoid  accidents  it  is  better  to  tie  the  cord,  in  spite  of  its  use- 
lessness  in  many  cases.  The  cord  should  be  tied  with  an  ordinary 
large  thread  wound  two  or  three  times  around  it.  One  ligature 
Bhould  be  placed  at  four  centimetres  from  the  umbilicus  and  one 
at  the  maternal  vulva.     The  cord  is  then  cut  between  these  two  at 


Management  of  Accouchement.  227 

one  centimetre  from  the  ligature  next  the  child.  This  ligature  of 
the  cord  Bhould  be  performed  after  the  complete  cessation  of  the 
vascular  pulsations  (live  to  ten  minutes  after  delivery). 

Care  consecutive  to  delivery. — Proceed  at  once  to  the  toilet  of  the 
woman  with  a  carbolic  solution,  1-50.  A  simple  vulvar  lava-,  is 
sufficient  in  normal  cases,  and  when  the  care  previously  indicated 
has  been  taken  during  accouchement.  If  not,  a  vaginal  injection, 
and  an  intra-uterine  injection,  if  needed,  will  he  given.  Perineor- 
rhaphy is  performed  if  necessary.  At  this  moment  it  is  necessary 
to  watch  the  condition  of  the  uterus  by  palpation  on  account  of  the 
frequency  of  haemorrhage.  The  physician  should  not  leave  the 
parturient  woman  for  an  hour  or  more  after  delivery  and  before 
leaving  he  should  be  well  assured  that  the  uterus  is  well  contracted 
by  grasping  it  through  the  abdominal  wall. 

Management  of  each  position  in  particular. — A.  Presen- 
tation of  the  vertex. — Internal  rotation. — In  the  case  of  a  posterior 
position  the  rotation  of  the  occiput  may  occur  late  and  impede  the 
progress  of  labor.  It  should  be  aided  when  there  exist  complete 
dilatation  and  pronounced  flexion  of  the  cephalic  ovoid,  and  when 
the  vertex  is  supported  by  the  permseum.  If  one  of  these  conditions 
dors  not  exist  it  will  be  well  to  wait.  The  internal  rotation  may  be' 
aided  with  the  fingers,  the  vectis,  or  the  forceps. 

Fingers. — Gliding  two  fingers  in  front  of  the  sacrum  to  push  the 
posterior  parietal  protuberance  forward,  or  two  fingers  behind  the 
pubes  to  push  the  brow  backward. 

Vectis. — The  vectis  is  not  much  used  at  present.  This  is  a  mis- 
take, for  in  some  cases,  notably  the  ones  now  under  consideration, 
it  is  capable  of  actual  service.  Slipped  in  behind  the  union  of  the 
occiput  and  parietal  bones  it  accentuates  flexion  and  causes  rotation 
by  the  pressure  it  permits  from  behind  forward. 

Foycvps . — The  forceps  should  only  be  employed  when  the  pre- 
ceding means  have  failed  and  when  there  is  no  hope  of  seeing 
spontaneous  delivery.  In  the  study  of  this  instrument  we  shall  see 
its  application. 

Disengagement  of  the  head. — It  is  necessary  to  use  care,  in  aiding 
extension  of  the  head  during  its  exit  through  the  vulva,  to  have  the 
occipitocervical  groove  in  contact  with  the  lower  part  of  the  pubes 
(Figs.  276-277).  Without  this,  disengagement  is  unfavorable  (Figs. 
278-279). 

In  cases  of  uterine  inertia,  the  disengagement  of  the  head  will  be 
delayed.  It  will  then  be  aided  by  the  use  of  the  fingers  or  of  the 
forceps. 

Fingers. — When  the  head  is  sufficiently  advanced  in  the  vulvar 
orifice,  two  fingers  in  the  rectum  can  hook  down  the  chin  and  favor 
cephalic  exten.-ion. 


228 


Management  of  Accouchement. 


Forceps. — The  employment  of  the  forceps  will  be  justified  and 
indicated  in  the  three  following  conditions  : 

1.  Maternal  danger.  —  Syncope;  eclampsia;  haemorrhage;  ex- 
cessive fatigue ;  elevation  of  temperature  to  39?-4.03  C. 

2.  Foetal  danger. — Acceleration  or  notable  retardation  of  the 
heart  sounds. 

3.  Arrest  of  accouchement. — Caused  either  by  uterine  inertia  or  by 
excessive  resistance  of  the  perinasum.  The  application  of  the 
forceps  is  authorized  when,  during  the  period  of  expulsion,  the  head 
has  remained  two  hours  at  the  same  point  of  the  parturient  canal. 
A  compression  of  the  same  point  of  the  maternal  tissues  for  more 
than  two  hours  exposes  to  gangrene  and  consecutive  fistulas. 


Figs.  276  and  277. — Disengagement  of  the  suboccipito  diameters  (favorable). 


Figs.  278  and  279. — Disengagement  of  the  occipito  diameters  (unfavorable). 

Immediately  on  exit  of  the  head  care  must  be  taken  to  wipe  away 
from  the  child's  mouth  the  mucus  which  may  penetrate  into  the 
respiratory  passages.  Finally,  the  finger  takes  note  if  the  cord  is 
around  the  neck.  If  so,  it  is  disengaged  by  passing  it  above  the 
head  or  by  gliding  it  over  the  shoulder,  or  finally,  if  it  is  too  tightly 
compressed,  by  cutting  it  between  two  ligatures,  or  if  time  presses, 
without  any  haemostatic  precaution. 

Disengagement  of  the  trunk. — The  head  should  be  sustained  imme- 
diately after  its  exit.  If  the  disengagement  is  tardy  the  women  is 
asked  to  bear  down  while  the  head  is  drawn  upward  to  favor  a  normal 
exit,  posterior  shoulder  first,  then  the  anterior.     If  this  fail,  the 


Management  of  Accouchement,  229 

head  is  then  lowered  to  disengage  the  anterior  shoulder  first.  The 
rtst  of  the  trunk  is  delivered  without  difficulty  by  drawing  slightly 
on  the  body,  one  hand  still  supporting  the  perinasum. 

B.  Presentation  of  the  face. — Period  qj  dilatation  of  tin  cervix. — I 
believe  the  different  means  advised  for  converting  a  face  into  a 
vertex  are  seldom  indicated  when  the  face  presentation  is  marked 
or  when  the  head  is  completely  extended. 

Period  of  expulsion. — The  rotation  of  the  chin  forward  in  the  mento- 
posterior positions  being  obligatory,  it  is  necessary  to  bring  it  for- 
ward at  any  price. 

Disengagement. — When  the  mento-cervical  groove  is  under  the 
pubes  the  flexion  of  the  head  should  be  favored.  The  other  indi- 
cations are  the  same  as  for  the  vertex. 

C.  Presentation  of  the  brow. — During  labor  the  indications  vary 
according  to  the  situation  of  the  head.  Before  complete  dilatation 
effort  is  made  to  transform  the  brow  into  vertex  or  face  by  the  aid 
of  external  manoeuvres,  internal,  combined,  or  with  the  aid  of  an 
instrument.  Transformation  into  a  vertex  presentation  is  preferable 
to  that  of  the  face.  At  complete  dilatation  the  previous  methods 
are  equally  employed  but  three  other  methods  occur,  version, 
forceps  and  embryotomy.  Version  causes  a  transformation  of  the 
brow  into  a  breech  position.  Podalic  version  by  internal  version 
can  be  followed  by  complete  extraction  or  left  incomplete.  The 
forceps  applied  at  the  superior  strait  may  grasp  the  head  with  or 
without  previous  reduction.  In  cases  where  none  of  these  methods 
has  been  successful  cephalic  embryotomy  remains.  When  dila- 
tation has  been  complete  a  certain  time  (the  head  being  still  at  the 
superior  strait)  these  procedures  may  still  be  employed,  but  as  labor 
advances  version  becomes  more  difficult.  When  the  fcetal  head  has 
penetrated  into  the  excavation  there  is  no  longer  a  question  of 
version ;  the  forceps  alone  remains  to  complete  delivery,  or  if  this 
instrument  fail  embryotomy  will  be  necessary.  When  the  median 
strait  has  been  passed  and  the  head  is  in  the  muscular  pelvis,  the 
soft  parts  only  oppose  a  relatively  slight  resistance,  which  the 
forceps  will  quickly  overcome. 

D.  Presentation  of  the  breech. — The  management  of  delivery  varies 
according  as  the  breech  is  incomplete,  thigh  variety,  or  presents 
one  of  the  three  other  varieties. 

1.  Breech,  complete  and  incomplete  (knees  and  feet). — The  manage- 
ment is  the  same  in  these  three  varieties. 

Period  of  dilatation  of  the  cervix. — In  some  cases  cephalic  version 
may  be  attempted  by  external  manoeuvres  before  rupture  of  the  bag 
of  waters,  and  after  rupture  the  same  version  by  mixed  manoeuvres. 


230  Management  of  Accouchement. 

The  woman  should  remain  recumbent  during  the  period  of  dilatation 
of  the  cervix  to  avoid,  as  much  as  possible,  rupture  of  the  membrane 
and  a  too  sudden  escape  of  liquid. 

Period  of  expulsion. — Three  points  dominate  and  sum  up  the  con- 
duct of  the  physician  during  this  period:  1.  To  place  the  woman 
in  the  obstetrical  position.  2.  Never  to  interfere,  except  in  com- 
plications, during  the  exit  of  the  cormic  ovoid.  3.  Always,  or 
almost  always,  to  interfere  during  the  exit  of  the  cephalic  ovoid. 

a.  To  place  the  woman  in  the  obstetrical  position,  that  is,  across 
the  bed,  the  legs  sustained  by  the  assistants,  or  each  foot  supported 
on  a  chair.  This  position  will  be  prescribed  when  the  breech 
arrives  at  the  vulva. 

h.  Never  to  interfere,  except  in  complications,  during  the  exit  of 
the  cormic  ovoid.  To  draw  on  a  limb  or  foot  is  so  easy  and  so 
tempting  in  the  desire  to  assist  the  woman,  but  it  is  deplorable 
practice.  It  is  sufficient  to  sustain  the  trunk,  to  avoid  dragging  on 
the  cord  and  to  watch  the  direction  of  the  back. 

c.  Always,  or  almost  always,  to  interfere  during  the  exit  of  the 
cephalic  ovoid.  When  the  trunk  has  been  expelled,  and  the  head 
still  remains  in  the  maternal  genital  organs,  the  funicular  circu- 
lation is  interrupted  by  the  compression  of  the  cord  between  the 
maternal  wall  and  the  foetal  part.  Thus  it  is  of  importance  to 
extract  the  head  promptly.  This  will  be  done  with  two  fingers  in 
the  mouth,  the  other  hand  grasping  the  foetal  neck.  The  chin  is 
carried  backward  and  the  hinge  movement  is  simulated  with  the 
hands,  as  in  the  normal  mechanism  of  delivery  of  the  breech.  In 
some  cases  the  forceps  will  be  necessary.  Embryotomy  will  be  use- 
ful only  in  cases  of  disproportion  between  the  foetus  and  the  partu- 
rient canal. 

2.  Incomplete  breech,  thigh  variety. — What  has  been  said  with 
regard  to  the  preceding  varieties  equally  applies  here,  except  that 
there  are  some  new  considerations  on  the  subject  of  extraction  of 
the  trunk.  When  the  lower  limbs  are  extended  the  obstetrician 
finds  difficulty  in  the  delivery  because  in  extraction  there  is  no 
available  part  of  the  foetus  to  be  grasped.  To  avoid  this  it  has  been 
proposed  to  draw  down  on  both  lower  limbs  by  a  hand  introduced 
into  the  uterus  before  engagement,  or  even  after  if  the  foetus  can 
still  be  pushed  up.  When  this  is  impossible  three  methods  of  ex- 
traction remain,  the  blunt  hook,  the  fillet,  and  the  forceps. 

The  hlu nt  Iwok. — The  finger  introduced  into  the  fold  of  the  groin 
and  curved  like  a  hook  may  serve  for  the  extraction  of  the  breech. 
It  is  the  best  of  blunt  hooks  and  less  dangerous  than  the  numerous 
instruments  of  this  form  that  have  been  advised. 

The  fillet  consists  of  a  cord  passed  around  one  of  the  thighs  of 
the  foetus  to  serve  for  traction.  Any  inoffensive  and  soft  substance 
will  answer.     It  is  passed  by  the  aid  of  the  fingers  or,  better,  by 


Management  of  Accouchement. 


■in 


the  use  of  a  hook  intended  for  this   apecial    purpose  (Fig.  'ISO). 
The  tractions  are  made  during  the  utero-abdominal  contractions. 

The  forceps  are  applied  over  the  trochanters  to  grasp  the  bitro- 
ohanteric  diameter  as  firmly  ns  possible. 


Fig.  280.— The  fillet. 

E.  Presentation  of  the  thorax. — During  the  period  of  dilatation  of 
the  cervix,  if  the  membranes  are  intact,  cephalic  version  will  be  at- 
tempted by  external  manoeuvres,  or  if  the  membranes  are  ruptured, 
this  is  performed  by  mixed  procedures. 

Period  nf  expulsion. — Immediately  after  complete  dilatation,  po- 
dalic  version  by  internal  manoeuvres  should  always  be  performed, 
no  account  being  taken  of  the  chances  of  spontaneous  evolution 
except  in  abortion.  In  cases  where  this  intervention  is  impossible 
embryotomy  is  indicated. 

F.  Presentation  of  the  abdomen  requires  the  same  management  as 
that  of  the  thorax,  with  the  difference  that  if  embryotomy  becomes 
necessary  it  is  not  section  of  the  neck  that  is  made  but  evisceration. 


232  Accouchement. — Delivery  of  the  Appendages. 


CHAPTER  XIII. 


ACCOUCHEMENT.— DELIVERY  OF   THE 
APPENDAGES. 

Delivery  of  the  fcetal  appendages  may  be  normal  (physiological) 
or  abnormal  (pathological).  These  terms  define  themselves.  I  shall 
only  study  here  the  physiological  delivery,  the  pathological  being 
reserved  for  later  discussion.  In  the  point  of  view  of  intervention 
delivery  is  called :  ^ 

Spontaneous  or  natural,  when  it  is  left  to  the  forces  of  nature 
alone ; 

Favored,  when,  by  expression  or  by  traction,  the  exit  of  the  ap- 
pendages is  aided ; 

Artificial,  when,  to  obtain  the  appendages,  it  is  necessary  to 
introduce  the  hand  or  instruments  into  the  uterine  cavity. 

A.  Mechanism. — Delivery  takes  place  in  three  stages : 

First  stage. — Detachment  of  the  appendages. — The  placenta,  de- 
tached by  a  mechanism  to  be  studied  later,  falls  on  the  uterine 
circle  which  at  this  moment  represents  the  internal  orifice  of  the 
uterus. 

Second  stage. — Uterine  expulsion. —  The  placenta  is  expelled 
from  the  uterine  cavity  into  the  vagina  by  passing  through  the 
portion  extending  from  the  uterine  circle  to  the  external  orifice, 
representing  the  engagement  of  the  placenta. 

Third  stage. — Vaginal  expulsion. — The  placenta  is  pushed  out  of 
the  vagina  through  the  vulvar  orifice,  representing  disengagement 
of  the  placenta. 

First  stage. — Detachment  of  the  placenta. — Two  theories  have 
been  advanced  to  explain  this  detachment : 

a.  Detachment  by  effusion  of  blood  (Baudelocque). — The  blood 
breaking  up  the  attachments  uniting  the  placenta  to  the  uterus,  is 
effused  between  these  two  organs,  and,  its  quantity  progressively 
increasing,  mechanically  separates  the  placenta  and  the  membranes 
from  the  uterus  (Fig.  281).  In  this  theory  the  uterine  muscular 
structure  plays  an  almost  passive  part. 

b.  Muscular  theory  (Matthews  Duncan). — Contrary  to  the  pre- 
ceding theory,  the  muscular  structure  here  plays  the  principal 
role;  it  is  the  retraction  and  contraction  of  the  organ,  which, 
progressively  diminishing  the  uterine  cavity,  pushes  the  placenta 


Arcnitrhcmeut. — Delivery  of  the  Appendages. 


238 


outward.  Effusion  of  blood  may  exist  but  it  play-  only  a  secondary 
role.  According  to  Baudelocque,  the  haemorrhage  is  inevitable  and 
indispensable;  according  to  Duncan,  it  ie  accessory  and  may  be 
absent  (Fig.  282  , 

If  Baudelocque'e  theory  were  exact,  it  should  apply  to  all 
But  it  cannot  be  accepted  in  placenta  preevia,  and  besides  the 
haemorrhage  of  delivery  of  the  appendages  is  often  so  slight  that  it 
(••mid  not  \»'  called  upon  to  explain  the  placental  detachment.  On 
the  contrary,  Duncan'-  theory  presents  no  exception-  and  should 
be  considered  as  well  founded.  It  is  the  action  of  the  uterine 
muscular  structure  which  causes  the  detachment  of  the  placenta 
and  of  the  membranes. 


Fig.  281. — Delivery. — First  stage.     Theory  of  Baudelocque.     S.  blood; 
U,  uterus ;    P,  placenta. 


Second  stage. — Uterine  expulsion. — The  detached  placenta  falls 
on  the  uterine  circle,  where  it  may  present  in  three  different  ways, 
by  its  uterine  surface,  by  its  edge,  or  by  its  festal  surface 

Presentation  of  the  uterine  surface  (Fig.  283)  takes  place  in 
about  five  cases  out  of  one  hundred.  The  placenta  covers  the 
uterine  circle  as  if  it  had  been  originally  inserted  on  the  contour  of 
this  orifice.  This  presentation  is  the  most  rare  and  can  he  con- 
sidered as  pathological.  It  is  usually  due  to  a  vicious  insertion  of 
the  placenta  or  to  partial  adhesions  of  the  placenta  or  of  the  mem- 
branes. 


234  Accouchement. — Delivery  of  the  Appendages. 

Marginal  presentation  (Fig.  284)  takes  place  in  about  twenty 
cases  out  of  one  hundred.  The  edge  of  the  placenta  engages  in  the 
uterine  circle,  and  arrives  first  in  the  vagina.  The  causes  are 
analogous  to  those  of  presentation  of  the  uteri  surface. 

Presentation  of  the  foetal  surface  (Fig.  285)  occurs  in  seventy- 
five  cases  out  of  one  hundred.  This  presentation  of  the  placenta 
should  be  considered  as  the  rule,  or  rather,  as  physiological,  the 
others  being  pathological.  It  is  to  the  placenta  what  the  vertex 
presentation  is  to  the  foetus. 

The  general  disposition  of  the  placenta  is  that  of  a  cup,  which  is 
adapted  to  the  uterus,  to  the  contour  of  the  uterine  circle,  and 
which  is  continued  by  the  cord  through  the  vagina  and  vulva  to  the 
exterior.  The  placenta,  pushed  by  the  uterine  retraction  and  con- 
traction, opens  the  uterine  circle  little  by  little  and  also  the  canal 
which  follows  it,  drawing  down  the  membranes  which  turn  around 
it  in  proportion  to  its  descent.  Tractions  on  the  cord  and  expression 
complete  the  detachment  of  the  membranes  commenced  by  uterine 
contraction.  Matthews  Duncan  believes  that  the  uterine  canal 
should  present  a  diameter  of  about  five  centimetres  to  allow  the 
passage  of  the  placenta. 

Third  stage. — Vaginal  expulsion. — When  the  placenta  has  fallen 
into  the  vagina  completely  the  woman  feels  a  vague  need  of  pushing. 
Under  the  influence  of  some  efforts  of  expulsion  the  placenta  pro- 
gresses toward  the  vulva,  appears  at  this  orifice  and  finally  passes 
it,  drawing  in  its  train  the  membranes.  As  at  the  uterine  orifice 
the  placenta  may  present  by  its  uterine  or  by  its  fcetal  surface  or 
by  its  edge.  In  general  the  presentation  is  the  same  at  both 
orifices,  unless  changed  by  interventions,  as  tractions  on  the  cord. 
When  the  placenta  presents  at  the  vulvar  orifice  by  its  fcetal  surface, 
the  membranes  are  inverted  and  the  ovum  offers  an  inverse  dis- 
position to  that  which  existed  in  the  uterine  cavity.  When,  on  the 
contrary,  there  is  a  marginal  presentation  or  a  presentation  of  the 
uterine  surface,  the  membranes  are  not  inverted  and  preserve  their 
primitive  disposition. 

B.  Symptoms  and  diagnosis. — To  recognize  the  different 
stages  of  the  delivery,  either  touch  or  vision  may  be  used,  following 
the  descent  of  the  cord.     Three  circumstances  may  present : 

1.  The  exploring  finger  meets  the  placenta  in  the  vagina.  The 
second  stage  is  terminated  and  the  third  is  in  progress. 

2.  The  placenta  is  at  the  level  of  the  uterine  circle,  or  engaged 
in  the  canal  which  follows  it.  The  first  stage  is  accomplished  and 
the  second  is  in  progress. 

S.  The  finerer,  as  far  as  it  can  reach  along  the  cord,  cannot  feel 
the  placenta]  mass.  Detachment  has  not  taken  place  and  the  first 
stage  is  in  progress. 


Accouchement. — Delivery  of  the  Appendages.  235 


Fig.  2S2. — Deliver}-. — First  stage.     Theory  of  Matthews  Duncan.     U,  uterus. 


Fig.  2S3. — Delivery. — Second  stage.     Presentation  of  the  uterine  face. 


236  Accouchement. — Delivery  of  the  Appendages. 

Digital  examination,  then,  gives  exact  information,  but  it  presents 
a  double  inconvenience ;  the  first,  of  being  painful,  and  the  second 
of  exposing  to  septicaemia.  Thus  it  is  better,  except  in  necessity, 
to  be  content  with  the  examination  of  the  cord. 


FlG.  284. — Delivery. — Second  stage.     Marginal  presentation. 
U,  uterus ;  S,  blood ;  P,  placenta. 

Examination  of  the  cord. — At  the  same  time  that  ligature  is  placed 
on  the  cord  near  the  umbilicus,  a  second  one  should  be  placed  at 
the  vulva,  as  a  funicular  index  permitting  the  descent  of  the 
placenta  to  be  followed.  When  this  index  is  at  seven  fingers' 
breadth  below  the  vulva,  the  placenta  is,  in  general,  at  the  uterine 
circle  and  even  engaged  in  that  orifice.  When  it  is  still  further 
from  the  vulva,  the  placenta  is  in  the  vagina,  the  second  stage  is 
accomplished  and  the  woman  feels  at  this  moment  a  local  malaise, 
which  excites  bearing  down. 

By  this  means  one  can,  without  digital  examination,  diagnosticate 
with  sufficient  precision  the  descent  of  the  placenta.  Touch  should 
only  be  resorted  to  when  delivery  of  the  placenta  does  not  occur  at 
the  end  of  an  hour  after  accouchement,  for  then  a  pathological  state 
is  entered  and  the  physician  is  authorized  to  seek  the  cause  of  this 
delay. 

[titration. — Physiological  delivery  of  the  placenta  lasts  from  some 
minutes  to  an  hour,  average  of  half  an  hour.  A  delivery  lasting 
more  than  an  hour  is  pathological. 


Accouchement, — Delivery  of  the  Appendages.  237 

C.  Management  of  delivery  oi"  the  placenta.  Four 
methods:     Expectation;  traction:  expression;  mixed  method 

Method  of  expectation. — To  leave  nature  to  act,  when  all  is  physi- 
ological, is  a  counsel  seductive  in  appearance.  Hut  is  it  so  in  prac- 
tice? Must  the  physician  wait  near  his  patient  BeveraJ  hours  until 
delivery  is  terminated ?  The  interest  of  the  woman,  above  all,  is 
responded.  Bui  the  interest  of  the  woman  is  not  our  waiting.  It 
is  had  practice,  on  the  contrary,  not  to  deliver  the  patient  as  soon 
as  possible,  to  be  enabled  to  change  her,  to  give  her  dry  clothes,  and 
to  permit  repose.  Thus  simple  expectation  is,  in  general,  abandoned 
and  has  few  chances  of  making  new  pro.^elyte.^. 


Fig.  285. — Delivery. — Second  stage.     Presentation  of  the  foetal  face. 
S,  blood :    P,  placenta. 

Method  of  traction. — The  principle  of  this  method  consists  in  aiding 
the  exit  of  the  ovuline  appendages  by  tractions  exerted  on  the  cord 
( Fig.  286).  The  third  stage  is  the  moment  of  choice  for  this  traction. 
The  cord  should  be  seized  with  a  dry  cloth  and  drawn  gently  out- 
ward. When  the  placenta  opens  the  vulvar  orifice  it  is  grasped 
with  the  free  hand  and  carefully  delivered  with  the  membranes. 

Method  of  expression. — To  replace  the  vis  a /route  by  the  vis  a  tergo 
has  been  the  idea  from  which  this  method  arose.  In  the  place  of 
drawing,  it  is  thought  preferable  to  push  (Fig.  287).  Crede's  name 
is  generally  attached  to  this  method.  The  cord  is  no  longer  to  be 
touched.     After  the  exit  of  the  fcetus,  almost  at  once  ("Winckel),  or 


238  Accouchement. — Delivery  of  the  Appendages. 

at  the  end  of  a  certain  time,  when  uterine  contraction  returns 
(Breisky),  the  uterus  is  grasped  with  the  whole  hand  and  squeezed 
like  a  sponge.  By  this  expression  uterine  retraction  and  contraction 
are  aided,  diminishing  the  capacity  of  the  uterus  and  obliging  the 
contents  to  escape.  Pressure  on  the  hypogastrium,  combined  with 
that  on  the  uterus,  is  sufficient  to  favor  evacuation  of  the  vagina. 


Fig.  286. — Delivery  by  traction.     U,  uterus  ;  S,  blood;   P,  placenta; 
R,  rectum  ;   V,  bladder. 

Mixed  method. — It  is  to  this  method  that  I  give  the  preference,  for 
it  unites  the  advantages  of  expression  and  of  traction  (Fig.  288). 

This  method  should  be  practiced  as  follows :  During  the  first 
stage  of  the  delivery,  while  the  funicular  ligature  has  not  descended 
to  seven  fingers'  breadth  below  the  vulvar  orifice,  it  is  sufficient  to 
place  one  hand  on  the  fundus  of  the  uterus,  to  assure  the  progres- 
sive retraction  of  the  organ  and  to  aid  it  by  slight  frictions.  "When 
the  first  stage  is  terminated,  after  having  grasped  the  cord  with  one 
hand  make  gentle  tractions  in  the  direction  of  the  perinseum,  while 
the  other  hand  expresses  the  uterus  through  the  abdominal  wall. 
This  intervention  should  always  be  practiced  with  slowness  and 
gentleness.  It  lasts  some  minutes,  quarter  of  an  hour,  sometimes 
half  an  hour  or  more.     The  accoucheur  should  not  forget  that  he  is 


Accouchement. — Delivery  of  thi   Appendages. 


289 


Fig.  2S7. — Delivery  by  expression. 


Fig.  2SS. — Delivery  br  mixed  method. 


240  Post-Partum. 

only  to  second  uterine  action.  During  the  third  stage  the  uterine 
expression  is  continued,  but  moderated,  less  in  the  aim  of  aiding 
the  delivery  than  in  that  of  preventing  inertia  and  haemorrhage. 
With  the  other  hand  the  placenta  is  drawn  on  by  the  aid  of  the  cord. 
When  the  placenta  makes  its  exit  it  is  left  to  lie  in  the  bed  or  in  a 
receptacle  placed  at  the  vulva  to  receive  it.  One  hand  is  still 
retained  on  the  abdomen  while  the  other  draws  the  membranes 
progressively  outward.  The  exit  of  the  membranes  should  be  par- 
ticularly slow,  for  the  least  impatience  at  this  moment  is  sufficient 
to  cause  their  rupture  and  to  favor  retention. 

After  delivery  it  is  well  to  leave  the  hand  on  the  fundus  of  the 
uterus  for  a  quarter  of  an  hour,  making  slight  friction  from  time  to 
time,  in  the  aim  of  watching  retraction  and  of  preventing  inertia. 


CHAPTER  XIV. 


POST-PARTUM. 

The  uterus  is  evacuated,  the  post-partum  commences,  it  will  be 
continued  or  not  by  lactation.  The  characteristic  fact  of  the  period 
is  the  genital  wound,  a  multiple  wound  which  commences  at  the 
raw  surface  left  by  the  placenta  and  is  continued  by  erosions  of  the 
cervix,  of  the  vagina  and  of  the  vulva.  All  these  ways  are  open  for 
the  penetration  of  microbes.  Thus  the  dominant  feature  of  this 
period  is  the  menace  of  puerperal  septicaemia. 

To  study  the  details  of  the  consequences  of  labor  it  is  necessary 
to  successively  consider : 
I.  The  mother. 
II.  The  child. 
III.  Lactation. 

I.  The  mother. 

A.  Modifications  oj  the  organism. — The  maternal  organism  modi- 
fied by  pregnancy,  modified  also  by  the  accouchement,  undergoes 
during  the  post-partum  new  changes  destined  to  restore  it  pro- 
gressively to  the  normal  state.  We  shall  study  these  phenomena  in 
their  relation  to  each  system. 

I.  Genital  system.  —  The  vulva  repairs  its  ruptures  by  first  or 
second  intention.  The  vagina  becomes  shortened  and  narrowed. 
The  uterus  undergoes,  in  its  return  to  normal  state,  important 


Post-Partum.  241 

macroscopic  and  microscopic  changes  in  the  body  and  the  cervix. 
The  diminution  of  the  volume  of  the  body  of  the  uterus  is  appre- 
ciated in  practice  by  the  height  of  the  fundus  of  the  organ.  The  dif- 
ferent modifications  which  affect  the  uterns  in  it-  return  to  the  normal 

state  are  included  in  the  term  involution  or  uterini  non. 


Internal 
orifice. 


External 
orifice 


Fig.  2S9. — Uterus  Post-parturr.. 

The  cervix  also  undergoes  important  modifications  to  regain  its 
normal  state.  The  uterus,  after  delivery  and  at  the  beginning  of 
post-partum,  is  composed  of  three  parts  (Fig.  289) ;  a  thick  superior 
portion,  the  body  of  the  uterus,  a  thin  inferior  portion  consisting  of 
two  parts,  the  cervix  and  an  intermediate  portion  which  diminishes 
progressively  to  form  the  isthmus.  The  uterus  during  post-partum 
is  the  source  of  two  phenomena  of  practical  interest,  the  after-pains 
and  the  lochia. 

Ajter-pains. — These  are  only  uterine  colics  analogous  to  those  pro- 
duced during  labor,  sometimes  during  pregnancy,  and  in  some 
women  during  menstruation.  Their  characteristic  symptom  is  the 
pain,  and  the  woman  compares  them  to  those  of  accouchement,  but 
of  less  intensity.  They  may  last  for  three,  four,  or  even  five  days. 
These  after-pains  have  no  other  inconvenience  than  that  of  being 
painful,  but  this  may  become  so  marked  as  to  require  active  treat- 
ment :  Tincture  of  digitalis,  ten  to  twenty  drops ;  tincture  of 
viburnum  prunifolium,  ten  to  one  hundred  in  twenty-four  hours, 
about  ten  drops  every  two  hours.  Uterine  massage.  Hot  cata- 
plasms. Antipyrine,  one  to  two  grammes  ;  hydrate  of  chloral,  same 
dose.  Sometimes  a  hot  vaginal  injection  or  an  mtra-uterme  in- 
jection gives  notable  relief.  But  the  most  certain  treatment  consists 
in  the  administration  of  opiates. 


•24-2 


Post-Part  id 


1.  Lochia.  —  The  lochia  is  constituted  by  a  genital  flow  of  post- 
partum occurrence.  The  principal  source  is  the  internal  surface  of 
the  uterus,  and  the  accessory  that  of  the  cervix,  vagina  and  vulva. 

The  lochia  is : 

From  the  first  to  the  third  day,  sanguineous. 

From  ihe  third  to  the  sixth  day,  muco-pus  tinged  with  blood. 

From  the  sixth  to  the  ninth  day,  muco-purulent. 

After  the  ninth  day  the  flow  is  normally  very  slight. 

The  lochia  is  composed,  in  the  beginning,  of  blood,  of  leucocytes, 
of  epithelial  cells,  of  mucus,  and  sometimes  of  the  debris  of 
membranes.  Exceptionally  the  lochial  discharge  is  very  small  in 
quantity,  in  other  cases  it  is  copious. 

2.  Mamma.  —  The  modifications  of  the  breasts  will  be  studied 
with  lactation. 

3.  Urinary  system. — The  urinary  secretion  is  active  during  the  post- 
partum, especially  the  first  few  days.  The  elimination  of  the  solid 
element  of  the  urine  is  also  augmented.  We  note  in  the  urine  the 
frequent  presence  of  glycose.  A  frequent  accident  is  the  retention 
of  urine.  The  bladder,  compressed  during  accouchement,  is  in  a 
state  of  paralysis,  or  paresis,  during  the  first  days  of  post-partum. 
To  avoid  accidents  palpation  of  the  abdomen  should  be  practiced  at 
each  visit  during  the  first  few  days.  Treatment. — Hot  cataplasms 
sometimes  favor  the  emission  of  urine.  Allow  the  patient  to  sit  up 
to  accomplish  micturition.  As  a  last  resource,  catheterism  should 
be  performed,  with  vigorous  antiseptic  precautions. 


1  TRAVAIL! 


Fig.  290. — Modifications  of  the  puerperal  pulse. 

4.  Respiratory  and  circulatory  systems. — The  modifications  of  the 
respiratory  system  are  not  yet  well  known.  Those  of  the  circulatory 
system  are  better  understood.  The  principal  phenomena  is  a 
notable  diminution  in  the  number  of  cardiac  pulsations.  They  may 
fall  to  thirty-five  a  minute.  This  retardation  of  rapidity  is  pro- 
duced a  little  after  accouchement  and  lasts  from  eight  to  twelve 
'lays  with  a  momentary  interruption  at  the  third  day  caused  by 
lactation  (Fig.  290).  The  blood  undergoes  a  relative  increase  of 
the  quantity  of  the  fibrin  and  of  the  white  corpusles. 

5.  Nervous  system. — After  the  accouchement  the  woman  is  fatigued 


Post-Partum.  248 

in  general,  but  the  excitement  of  labor  and  the  joys  oi  maternity 
most  often  prevent  immediate  repose,  and  this  seldom  follow  -  before 
the  end  of  two  or  three  hours.  Even  then  it  is  often  interrupted  by 
after-pains.  Very  often  after  delivery,  or  a  little  before,  the  patient 
has  a  slight  chill  without  elevation  of  temperature  or  acceleration 
of  the  pulse.  This  is  a  physiological  phenomenon  and  without  im- 
portance. 

o.  The  Digestive  system. — The  appetite  quickly  returns.  Light 
nourishment  should  be  given.  Constipation  is  the  rule  and  must 
be  combatted  by  appropriate  measures. 

7.  General  state  (temperature,  nutrition). — The  temperature  in  ;i 
normal  state  should  never  attain  38  C.  during  post-partum.  When 
this  degree  is  attained,  there  exists  some  complication.  During 
simple  regression,  without  lactation,  nutrition  seems  active  in  all 
it-  processes.  Lactation  modifies  these  conditions.  Under  its 
influence  absorption  and  elimination  appear  active,  and,  on  the 
contrary,  assimilation  and  disassimilation  are  retarded. 

B.  Hygiene  of  post-partum. — Two  points  remain  for  discussion: 
Genital  antisepsis,  and  the  gradual  resumption  of  the  usual  mode 
of  life. 

Genital  antisepsis. —  The  nil  no- toilet  should  be  made  with  a  solution 
of  carbolic  acid,  1-50,  or  bichloride  of  mercury,  1-4000,  using  old 
linen  raurs  or  absorbsnt  cotton  sponges  proscribed  because  of  their 
doubtful  asepsis).  In  the  interval  of  the  toilets  an  antiseptic  tampon 
of  dry  cotton  should  be  applied  to  the  vulva,  simply  held  in  place 
by  apposition  of  the  thighs. 

Vaginal  injections.  —  Vaginal  injections  are  used  to-day  by  the 
majority  of  obstetricians,  one  to  three  times  a  day,  with  a  solution 
of  carbolic  acid  or  bichloride  of  mercury.  If  antiseptic  precautions 
have  been  taken  during  accouchement  and  also  during  the  latter 
part  of  pregnancy,  injections  during  post-partum  a.e  useless  and 
they  are  not  without  inconvenience,  for  they  expose  to  the  pene- 
tration of  air  into  the  genital  organs,  a  favorable  condition  for  the 
development  of  septicaemia.  In  a  general  way  they  should  be 
reserved  for  cases  where  antisepsis  has  been  incomplete  during 
preguancy  or  labor,  for  those  where  a  grave  intervention  during 
mchement  has  exposed  to  the  penetration  of  septic  agents,  and 
finally,  for  those  where  some  symptom  indicates  the  presence  of 
pathogenetic  microbes  in  the  interior  of  the  genital  organs. 

Intra-uterine  injection*.  —  These  injections  are  only  employed  in 
special  conditions,  to  remedy  a  beginning  septicaemia. 

Gradual  resumption  of  the  usual  mode  of  life. — After  accouchement, 
in  the  absence  of  any  complication,  the  patient  should  conform  to 
the  following  precept : 


244 


Post-Part  am. 


First  fortnight. — Bed. 
First  week : 

First  half — dorsal  decubitus. 
Second  half — lateral  or  dorsal  decubitus  at  will. 
Se#ond  week : 

First  half — the  head  may  be  raised  by  two  to  four  pillows. 
Second  half — the  puerpera  may  sit  up  in  bed,  to  eat,  nurse, 
etc.     At  the  end  of  the  second  week  she  may  get  up. 

Second  fortnight . — House. 
Third  week : 
Lounge  and  reclining  chair.     Duration  of  remaining  out  of 
bed,  an  hour  more  each  day : 
First  day,  one  hour. 
Second  day,  two  hours. 
Third  day,  three  hours,  etc. 
Fourth  week : 

Arm  chair;  rocking  chair,  in  case  of  fatigue.     At  the  end  of 
fourth  week  patient  may  go  out. 


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7000 

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25  Gm. 
per  day. 


20  Gm. 
per  day. 


15  G  m. 
per  day. 


10  G  m. 
per  day. 


Fig.  291  — Weight  of  the  child  during  the  first  year. 

II.  Child. 

A.  Pliysiological  jihenomcna. 

1.  Weight.  —  Tha  average  weight  of  the  new-born  is  about  three 
thousand  grammes  at  the  moment  of  birth.  This  diminishes  one 
hundred  grammes  during  the  first  two  days  and  is  regained  in  five 
days  more,  so  that  at  the  end  of  the  first  week  the  weight  is  identical 
with  that  at  birth.     The  daily  augmentation  of  the  child's  weight, 


Po8t-Partum.  -i\:, 

outside  of  these  first  seven  days,  is  variable,  but  may  be  fixed  at  a 
daily  average,  a-  represented  in  Fig.  291. 

2.  Temperature,  circulation,  respiration. — The  temperature  is  sub- 
ject to  an  initial  depression  and  then  attains  its  maximum  the  day 
utter  birth,  then  it  oscillates  between  30  and  'M  C.  The  initial 
depression  is  greater  in  proportion  as  the  birth  is  farther  from 
normal  term.  The  number  of  pulsation-  oscillate  around  one 
hundred  and  twenty  per  minute.  The  respiration  gives  variable 
results. 

3.  Cord. — The  cord,  during  the  days  consecutive  to  birth,  desic- 
cates. A  groove  filled  with  a  purulent  serurn  appears  around  its 
umbilical  insertion.  The  cord  falls  off  spontaneously  between  the 
third  and  sixth  day.  Sometimes  there  persists  a  small  ulceration 
at  the  umbilicus  that  requires  dressing. 

4. — Dentition. — Milk  teeth  (twenty). — The  milk  teeth  appear  in  the 
following  order : 

Median  incisors,  four  toward  the  sixth  month. 
Lateral  incisors,  four  toward  the  ninth  month. 
First  molars,  four  toward  the  twelfth  month. 
Canine,  four  toward  the  fifteenth  month. 
Second  molars,  four  toward  the  eighteenth  month. 


Fig.  293. — Order  of  eruption  of  the  eight  incisors  (milk  teeth). 

All  the  lower  teeth  appear  before  the  corresponding  upper  teeth, 
except  in  the  case  of  the  lateral  incisors  where  this  order  is  inverted 
(Fig.  293).  The  preceding  dates  are  only  approximate.  The  first 
teeth  often  appear  later  than  the  sixth  month  and  they  are  ex- 
ceptionally seen  at  birth. 

The  permanent  teeth  successively  replace  the  milk  teeth  which  fall 
before  their  appearance. 
Successive  order : 

First  molars,  seventh  year. 

Central  incisors,  eighth  year. 

Lateral  incisors,  ninth  year. 

First  bicuspids,  tenth  year. 

Second  bicuspids,  eleventh  year. 

Canine,  twelfth  year. 

Second  molars,  thirteenth  year. 

Wisdom  teeth,  twentieth  year  (eighteenth  to  twenty-fifth  year). 


246 


Post-Partuni. 


5.  Digestion. — The  milk  undergoes  digestion  in  the  stomach  and 
intestine,  and  is  absorbed  from  the  latter.  The  stools  of  the  new- 
born child  pass  through  three  successive  periods  : 

Meconial  period  (three  days). — The  child  evacuates  the  meconium 
accumulated  in  the  intestine  during  pregnancy.  This  stool  is 
greenish  and  syrupy. 

Transitional  period  (one  day). — The  meconium  is  mixed  with  di- 
gested milk. 

Lactational  period. — The  residue  of  the  digested  milk  gives  an 
aspect  resembling  that  of  scrambled  eggs.  The  stools  number,  at 
first,  from  two  to  four  a  day,  later,  toward  the  second  month,  from 
one  to  three. 

6.  Cutaneous  phenomena. — The  child  passes  through  three  suc- 
cessive phases,  which  last  about  three  days  each:  1.  There  is  an 
acute  cutaneous  congestion,  caused  by  contact  with  the  air.  2.  There 
is  a  variety  of  icterus  caused  by  the  transformation  of  the  pigment 
deposited  by  the  blood  by  the  congestive  phase.  3.  The  child  be- 
comes pale  and  gradually  takes  its  normal  rose  color. 


s_\\\_w.v 
Fig.  295  — Section  of  the  couveuse. 

B.  Hygiene. — 1.  Vision. — The  e^es  should  be  attentively  watched 
and  carefully  inspected  at  each  visit.  This  precaution  is  necessary 
on  account  of  the  dangers  of  purulent  ophthalmia. 

2.  Cries,  Sleep. — The  cries  are  normal  when  they  are  of  slight 
intensity  and  duration.  When  they  become  intense  and  prolonged 
they  indicate  suffering,  the  cause  of  which  should  be  sought  most 
often  in  hunger,  thirst,  or  obstruction  by  the  clothing.  Sleep  gener- 
ally follows  after  nursing.  It  should  take  place  in  the  cradle  and 
not  in  the  arms  of  the  nurse.  The  child  should  be  laid  on  its  side 
in  the  cradle  to  avoid  obstruction  of  the  respiratory  passages  if 
vomiting  ensues. 

3.  Toilet. — It  will  be  well  to  give  the  child  a  hot  bath  of  some 
minutes  every  morning,  or  to  follow  the  English  system  of  cold  or 


Post-Partum. 


■J  17 


tepid  baths,  commencing  during  the  bol  season.  Daring  the  course 
of  twenty-four  hours  the  ano-genitaJ  region  should  receive  two  to 
four  cleansings,  followed  by  powdering  with  -tan-h,  lycopodium  or 
talcum. 

-1.  Temperature. — The  new-born  child  is  very  sensitive  to  the 
thermic  variations  met  in  its  new  life.  To  avoid  these  changes  the 
temperature  should  be  kept  as  nearly  as  possible  between  16  to  18°. 
For  children  born  before  term  the  convenses  introduced  by  Tarnier 
can  be  used  with  advantage  (Figs.  295  and  296  . 


Fir,.  296 — Exterior  view  ot  the  couvcu^e. 

III.  Lactation. —  Maternal  lactation. —  After  conception  and 
during  pregnancy,  the  glandular  lobes  of  the  breasts,  besides  con- 
gestion, assume  a  notable  development  by  proliferation  ot*  their 
elements.  If  at  tins  time  an  antero-posterior  section  is  made  (Fig. 
± »7 1  we  note  the  following  details  :  Beginning  at  the  nipple  we  find, 
in  following  a  galactophore,  that  it  presents  a  fusiform  dilatation 
and  then  resumes  its  former  dimensions  to  finally  ramify  in  the 
lobe  to  which  it  belongs.  The  canals  and  glands  are  formed  by  two 
layers,  the  eccentric  of  connective  tissue,  the  concentric  of  epi- 
thelium. The  epithelium  is  cylindrical  in  the  galactophore,  flattened 
and  less  rounded  in  the  glandular  culs-de-sac.  This  glandular  epi- 
thelium plays  the  essential  role  in  the  secretion  of  the  milk  and  of 
the  colostrum.  The  globules  of  the  milk  are  formed  at  the  expense 
of  the  epithelium  (Fig.  298)  and  the  other  elements  are  secreted  by 
the  glandular  wall.  The  colostrum  is  constituted  by  the  same 
elements  as  the  milk,  but  differs  by  being  more  aqueous  and  by 
having  the  globules  still  contained  in  the  muriform  body. 

The  establishment  of  the  flow  of  milk  is  characterized,  during  the 
first  twelve  hours,  by  an  intense  congestion  of  the  breasts  which 
become  painful  and  tender,  then  the  lacteal  secretion  is  established, 


248 


Post-Partum. 


the  tension  diminishes  and  if  the  woman  nurses  the  secretion  con- 
tinues. The  establishment  of  the  now  of  milk  is  accompanied  by 
malaise,  often  by  cephalalgia  and  acceleration  of  the  pulse.  But 
the^fever  that  before  antisepsis  was  often  observed  at  this  moment 
was  only  a  slight  septicemic  manifestation.  Milk  fever  does  not 
exist.  In  the  normal  state  the  sequelae  of  the  post-partum  are 
afebrile ;  the  thermometer  should  not  attain  38°  C. 


Thoracic  wall. 

*  Muscular  layer. 
Cellular  tissue. 

A  lobe  of  th^  mammary  gland. 


Areolar  muscle. 
(    Montgomery's  tubercle  and  ac- 

<  cessory  lactiferous  duct  proceed- 
ing from  an  accessory  gland. 

Lactiferous  sinus. 

Muscle  of  the  nipple. 

Openings  of  the  lactiferous  duct. 


(    Montgomery's  tubercle  and  ac- 
<  cessory  lactiferous  duct  proceed- 
ing from  a  lactiferous  sinus. 
Areolar  muscle. 


A  lobe  of  the  mammary  gland. 


.  Cellular  tissue. 


Fig.  297. — Schematic  section  of  the  breast. 

With  regard  to  allowing  the  woman  to  nurse  the  child,  this  de- 
pends upon  the  general  and  the  local  state.  The  majority  of  chronic 
diseases  are  not  a  contraindication  for  lactation,  among  them 
tuberculosis  merits  special  mention.  Every  woman  subject  to 
tuberculosis,  or  even  predisposed  to  this  disease,  should  renounce 
lactation.  Hysteria  and  pronounced  anaemia  are  also  contraindi- 
cations. 


Po8t~Pa/rtum. 


249 


oO 

0° 

I 

0 


o  O 
o 

0 


0  o 


i° 


IB1 


o  o        o 
.O.o 

o 


0oc 

(C) 


Fig.  298. — Formation  of  milk  globules.     (A),  epithelial  cell;  (B),  distention  of  the 
cell  by  fatty  granules;   (C),  rupture  of  the  cell,  freeing  the  milk  globule. 

A  flat  or  urnbilicated  nipple  renders  lactation  difficult,  sometimes 
impossible,  but  often  this  can  be  remedied,  as  will  be  seen  later. 
The  development  of  the  gland  and  the  abundance  of  colostrum 
should  be  taken  into  serious  consideration.  However,  so  far  as 
local  examination  is  concerned,  great  reserve  is  necessary,  for  often 
the  physician  is  wrong  in  his  prognosis. 


Budin 


%uvard 


Fig.  299. — Breast  pumps. 

If  the  nipple  be  flattened  the  child's  lips  are  unable  to  suck.  Even 
when  it  is  normal,  the  manipulations  of  the  child  may  produce 
fissure  that  becomes  very  painful.  To  obviate  the  difficulties  in 
such  cases  the  breast-pump  will  be  useful  (Fig.  299). 


250  Eclampsia. 


CHAPTER  XV. 


PUERPERAL.  PATHOLOGY.— GENERAL 
DISEASES.— ECLAMPSIA. 

An  intense  influenza  may  exceptionally  cause  abortion  or  pre- 
mature delivery.  Typhoid  fever  causes  premature  expulsion  in  a 
good  half  of  cases.  The  same  is  true  with  regard  to  cholera.  Preg- 
nancy confers  a  relative  immunity  against  malaria.  In  cases  of 
intermittent  fever  during  pregnancy,  quinine  seems  to  concentrate 
its  influence  against  the  malarial  condition  and,  far  from  being 
abortive,  prevents  premature  expulsion.  The  exanthemata  occurring 
during  pregnancy  cause  abortion  as  follows :  Measles  in  one-half 
of  the  cases;  scarlatina  in  a  proportion  difficult  to  establish;  with 
the  confluent  form  of  small-pox  abortion  is  the  rule ;  vaccination  of 
the  pregnant  woman  does  not  interrupt  the  progress  of  pregnancy. 
Erysipelas  during  pregnancy  often  causes  premature  expulsion 
and  its  prognosis  during  the  post-partum  is  always  serious.  Pdieu- 
matism  occurring  during  the  puerperal  state  may  show  itself  in 
three  forms — a  more  or  less  generalized  articular  rheumatism,  a 
mono-articular  rheumatism,  and  finally,  a  uterine  variety,  simply 
characterized  by  uterine  pains. 

Pregnancy  by  aggravating  scrofulosis  predisposes  to  the  develop- 
ment of  tuberculosis.  The  majority  of  phthisical  patients  are 
badly  influenced  by  the  puerperal  state.  Beside  tuberculosis  inter- 
feres with  the  development  of  the  fcetus.  This  disease  is  transmitted 
through  the  placenta. 

Pregnancy  occurring  during  the  evolution  of  syphilitic  mani- 
festations aggravates  their  character  and  prolongs  their  duration. 
If  the  onset  of  syphilis  dates  back  several  years,  its  influence  on 
pregnancy  will  probably  be  nul  and  the  child  unaffected.  If  syphilis 
is  transmitted  to  the  woman  at  the  moment  of  conception,  the  child 
will  almost  surely  be  syphilitic.  When  syphilis  is  transmitted  to 
the  woman  after  conception,  during  pregnancy,  the  contamination 
of  the  child  is  to  be  feared  in  proportion  as  the  beginning  of  the 
disease  approach  the  date  of  conception,  and  less  to  be  dreaded  as 
it  is  near  term. 

Eclampsia. — Eclampsia  is  a  disease  characterized  by  a  series 
of  convulsive  attacks  analogous  to  those  of  epilepsy,  occurring  at  a 
variable  period  of  the  puerperal  state,  most  often  near  accouchement. 


Eclampsia,  251 

Symptomatology. — Prodromata,  though  often  wanting,  are  more 
frequent  in  eclampsia  of  pregnancy  than  in  that  of  labor,  and  in 
eclampsia  of  labor  than  in  thai  of  post-partum.  They  consisl  of 
cephalalgia,  especially  frontal,  with  weakening  of  the  memory  and 
intellectual  apathy,  bilious  or  alimentary  vomiting,  insomnia, 
malaise,  vertigo,  and  sometimes  prolonged  lumbago. 

But  the  three  principal  prodromata,  which  constitute  a  Bort  of 
premonitory  tripod,  are  : 

The  disturbances  of  vision  (visual  fatigue,  cloudiness,  hemiopia, 
diplopia,  complete  blindness). 

The  epigastric  pain  (result  of  the  dyspnoea). 

The  dyspnoea  (result  of  the  insufficiency  in  the  functions  of  the 
lungs). 

Sometimes  these  prodromata  follow  several  days  or  weeks  before 
the  first  attack,  again,  they  may  only  precede  it  by  a  few  seconds. 

Albuminuria  can  also  be  considered  as  one  of  the  most  important 
of  the  prodromata  of  eclampsia,  but  it  is  convenient  to  separate  it 
from  the  preceding  symptoms,  which  are  subjective,  as  it  can  only 
be  found  by  the  use  of  objective  researches. 

Lead  poisoning  very  frequently  causes  the  death  of  the  foetus 
during  pregnancy,  and  also  that  of  the  child  after  birth,  on  account 
of  its  lack  of  development.  The  influence  of  the  husband  is  analo- 
gous to  that  of  the  mother,  though  less  marked.  Poisoning  by 
tobacco  occurs  by  the  penetration  of  nicotine  into  the  amniotic 
liquid  during  pregnancy  and  into  the  milk  after  accouchement. 
The  influence  of  this  poisoning  on  the  production  of  abortion 
although  probable  is,  however,  disputed. 

Under  the  term  progressive  pernicious  anaemia,  Gusserow  has  de- 
scribed a  disease  of  pregnancy  characterized  by  the  progressive 
diminution  of  the  red  globules,  terminating  in  anaemia  and  in  death. 
This  disease  is  probably  only  an  exaggeration  of  the  anaemia  common 
to  pregnancy. 

Attack.— The  attack  of  eclampsia  is  subdivided  into  four  periods, 
invasion,  tonic  spasm,  clonic  spasm  and  coma,  followed  by  an  in- 
terval of  calm. 

1.  Invasion  (duration  half  a  minute). — The  face  is  the  part  first 
attacked.  The  forehead  wrinkles  and  becomes  smooth ;  the  eyelids 
lower  and  raise  ;  the  ocular  globe  turns  in  various  directions  until 
the  pupil  is  carried  upward ;  the  pupil  is  dilated  and  insensible  to 
light;  the  wings  of  the  nose  are  pinched  and  depressed;  the  mouth 
twitches  and  is  soon  drawn  to  one  side,  most  often  to  the  left ;  the 
head  undergoes  occillations  drawing  it  to  the  right  or  left  and  soon 
fixing  it  definitely  to  the  left. 

'2.  Tonic  spasm*  (duration  one  minute). — After  these  facial  move- 
ments, a  second  period  follows  characterized  by  generalized  tonic 


252  Eclampsia. 

convulsions.  The  features  become  immobile ;  the  Lead  is  drawn 
backward ;  the  thorax  is  fixed ;  respiration  suspended ;  the  arms 
^ire  against  the  body,  the  forearms  in  pronation,  the  fingers  closed 
and  around  the  thumb ;  the  abdominal  wall  is  tense ;  the  lower 
limbs  stiffened.  Often  the  body  describes  an  arc  of  a  circle  with 
its  two  extremities,  the  head  and  feet,  supported  by  the  bed.  The 
respiration  being  suspended,  the  circulation  is  interrupted  so  that 
a  general  cyanosis  quickly  follows. 

3.  Clonic  spasms  (dwation  two  to  three  minutes). — The  clonic 
convulsions  invade  the  whole  body,  from  the  head,  where  they  com- 
mence, to  the  feet.  The  face  is  agitated  by  movements  analogous 
to  those  of  the  onset,  but  more  violent  and  more  prolonged.  The 
tongue  projects  between  the  teeth  and  is  often  bitten.  After  the 
face,  all  the  head,  then  the  thorax,  the  upper  limbs,  the  abdomen 
and,  finally,  the  lower  limbs  become  involved  in  convulsive  move- 
ments.    This  general  convulsion  soon  gives  way  to  coma. 

4.  Coma  (duration  quite  variable,  from  some  instants  to  several 
hours). — After  the  period  of  agitation  there  follows  a  comatose 
sleep.  Then  the  patient  returns  to  her  senses  completely,  or  she 
remains  in  a  state  of  somnolence,  or  finally,  she  does  not  recover 
from  the  comainto  which  she  has  been  plunged  by  a  last  attack. 
Besides  the  symptoms  already  given,  there  is  sometimes  produced 
an  involuntary  evacuation  of  urine  and  feces,  during  or  at  the  end 
of  the  clonic  spasms. 

Interval  between  the  attacks. — The  duration  of  this  interval  is  quite 
variable,  sometines  it  is  nul,  two  or  several  attacks  succeeding  each 
other  without  interruption,  sometimes  it  amounts  to  several  hours. 

The  temperature  sometimes  remains  normal,  or  even  descends 
below  normal,  most  often  it  rises  to  38-39°  C.  Its  ascension  is  in 
proportion  to  the  gravity  of  the  case.  The  pulse  follows  the  temper- 
ature. 

Albuminuria  usually  exists  for  some  time,  occasionally  it  only 
appears  during  the  attack,  exceptionally  it  is  completely  wanting. 

The  oedema,  the  puffmess  of  the  face,  is  accentuated  under  the 
influence  of  the  attack,  to  such  a  point  that  the  swelling  of  the  face 
renders  the  person  unrecognizable. 

Duration. — Sometimes  the  eclampsia  is  confined  to  a  single  attack 
and  only  lasts  a  short  period.  Usually  there  are  from  five  to  twenty 
attacks.  But  their  number  may  be  much  more  considerable,  as 
Crettet  cites  a  case  having  one  hundred  and  sixty. 

Terminations. — Cure  occurs  by  a  simple  cessation  of  the  attacks 
and  of  coma.  It  may  be  complete,  or  incomplete  leaving  behind  it 
disturbances  of  memory  and  of  vision,  an  habitual  stupor  and  slow- 
ness of  action,  a  persistent  anaemia  and  even  mania.  Death  is  pro- 
duced by  the  progress  of  the  poisoning  of  eclampsia,  exceptionally 
during  the  attack  by  asphyxia  and  syncope,  by  a  complication, 


Eclampsia.  258 

puli  nonary  congestion  and  oedema,  cerebral  haemorrhage  and  oedema, 
asphyxia  resulting  from  a  considerable  swelling  of  the  tongue,  and 
by  independent  complications,  such  as  puerperal  septicaemia  or 
grave  genital  haemorrhages. 

Pathological  anatomy. — Varied  lesions  are  found  hut  none  of  them 
are  constant. 

Nervous  system. — Serous  infiltration,  congestion,  anaemia,  haemor- 
rhages of  the  meninges. 

Respiratory  system. —  Lungs,  congestion,  apoplexy,  oedema,  em- 
physema.    Pleural  cavities,  serous  infiltration. 

Circulator!/  si/stem. — Heart,  puerperal  modifications. 

Urinary  system.  —  Frequent  but  not  constant  alteration  of  the 
kidneys,  presenting  a  simple  hyperemia,  or  the  lesions  of  a  recent 
or  an  old  nephritis. 

Digestive  system  and  appendages. — In  the  digestive  system,  only 
the  9tate  of  the  liver  is  of  importance.  This  organ  may  be  the  seat 
of  an  advanced  fatty  degeneration,  multiple  haemorrhages,  lesions 
of  diffused  parenchymatous  hepatitis. 

Genital  system. — State  of  the  organs  in  relation  with  the  period  of 
the  puerperal  state  in  which  death  takes  place. 

Pathogeny. — I  present  in  resume  in  the  following  table  a  view,  as 
a  whole,  of  the  different  theories,  comprising  therein  the  theory  of 
general  arrest  of  organic  elimination  with  which  I  will  close. 

Pathogenetic  theories  of  eclampsia. 

A.  Eclampsia — neurosis. 

1.  Mauriceau. 

'2.  Cohen :  neurosis,  having  its  point  of  departure  in  the 
uterine  reflex. 

B.  Eclampsia — modification  of  the  nervous  centers. 

1.  Mauriceau:  congestion  or  anaemia. 

2.  Marshall  de  GaM :  cerebral  cedema. 

3.  Traui.e :  anaemia  followed  by  cedema. 

C.  Eclampsia — alterations  of  the  blood. 

1.  Renal  theory,  1818.     Blackall  and  Wells  (Cotngno). 

Uraemi  a — Wilson 

.        .  .        )  Frerichs :  formation  in  the  blood. 

Amnionaemia—  \  „    ..       ,  ,.  ,,      .   ,     ,. 

J  lreitz  :  formation  in  the  intestines. 

Creatinaemia — Schottin. 

Urochronaemia — Thudichum. 
Oxalaemia — B.  Jones. 
Potassiaemia — Despine. 
Urinaemia — Peter. 

2.  Theory   of    general    elimination,  1818.      Riviere    and 

Anvare. 


25-4  Eclampsia. 

Neurotic  eclampsia  is  not  accepted  at  present,  nor  is  the  influence 
exercised  by  the  modifications  of  the  nervous  centers. 

The  renal  theory  contains  a  large  portion  of  the  truth.  However, 
it  is  not  completely  satisfactory  for  the  following  reasons : 

1.  Apyrexia  is  the  rule  in  urinsemia  and,  on  the  contrary,  fever  in 
eclampsia. 

2.  The  urinary  secretion  is  sometimes,  although  exceptionally, 
normal  in  eclampsia  (eclampsia  without  albuminuria). 

3.  Sometimes  eclampsia  presents  a  great  analogy  with  grave 
icterus  (diffuse  parenchymatous  hepatitis),  the  origin  of  which  can- 
not be  related  to  urinsemia. 

These  objections  disappear  if,  in  place  of  localizing  in  the  kid- 
ney, the  functional  disturbance  which  causes  eclampsia,  is  extended 
to  all  the  eliminating  organs.  So  far  as  these  different  organs  are 
concerned  we  have : 

Kidneys. — Urimeinia;  albuminuria;  anuria. 

Liver. — Hepataemia;*  icterus;  acholia. 

Intestine. — Intestinaeinia ;  constipation. 

Lungs. — Pneuniaenia;  dyspnoea. 

Skin. — cutaemia;  cutaneous  dryness. 
Among  the  different  symptoms,  indicating  the  functional  dis- 
turbance of  the  eliminating  organs,  the  cutaneous  dryness  and  the 
constipation  (which  is  actually  an  intestinal  dryness)  are  of  small 
importance  on  account  of  their  frequence  and  common  occur- 
rence. Dyspnoea  is  a  marked  premonitory  symptom  of  eclampsia. 
Icterus  hardly  ever  occurs  except  during  eclampsia  itself,  but  it  is 
far  from  being  rare,  especially  in  serious  cases.  The  acholia  is 
only  incomplete  and  difficult  of  appreciation.  The  anuria  some- 
times becomes  complete  during  the  attack,  but  as  a  premonitory 
symptom  there  is  only  observed  a  diminution  of  urine. — Albumin- 
uria is  the  most  important  premonitory  symptom. 

JEtiology. — Parity:  proportion,  four  primiparae  to  one  multi- 
para. Twin  pregnancy  and,  in  general,  any  exaggerated  distention 
of  the  uterus  predisposes  to  eclampsia.  Any  difficult  accouchement 
may  become  a  cause  of  this  disease.  Heredity  seems  to  play  some 
part  in  the  production  of  eclampsia.  Compression  of  the  ureters  or 
of  the  urethra  (retention  of  urine)  by  the  gravid  uterus  may  become 
a  cause,  by  interrupting  the  function  of  the  kidney.  Blot  has 
demonstrated  that  eclampsia  is  most  frequent  among  epileptics. 

*  Hepatcemia  indicates  the  accumulation  in  the  blood  of  all  the  elements  produced  by 
the  default  of  the  hepatic  function  (suppression  of  the  uro-poietic,  hsemato-poietic  and 
biliary  functions)  or  by  a  deviation  of  function  (bile  secreted  and  thrown  into  the  bloodl. 
For  the  intestine  I  also  say  inlestinczmia,  and  not  stercoramia,  for  stercorasmia  indi- 
cates the  presence  in  the  blood  of  material  contained  with  the  feces,  while  here  there 
is  more  a  suppression  of  those  that  furnish  the  intestinal  secretion.  Likewise  pneumcatnia, 
and  not  asphyxia,  for  asphyxia  is  the  simple  deprivation  of  oxygen,  while  I  note  es- 
pecially the  absence  of  the  elimination  of  the  toxic  alkaloid.  Finally,  for  the  skin,  we 
have  cutaemia  and  not  sudora?mia. 


Eclampsia.  255 

The  contagion  of  eclampsia  itself  cannot  be  admitted,  but  m  di- 
of  the  eliminating  organs  (infectious  nephritis,  infectious  pneu- 
monia) may,  by  contagion,  indirectly  cause  an  evolution  of  puer- 
peral convulsions. 

Frequency. — Albuminuria  exists  in  about  one-tenth  of  pregnenl 
women,  and  eclampsia  in  one  thirty-fifth  of  the  albuminurias  of 
pregnancy,  giving  a  proportion  of  eclampsia  of  one  three-hundred- 
and-hftiehs  of  pregnant  women. 

Prognosis. — About  one-quarter  of  the  cases  of  eclampsia  die,  and 
two-thirds  of  the  children  succumb. 

Treatment. — The  therapeutic  means  that  are  employed  against 
eclampsia  are  very  numerous.     They  can  be  grouped  as  follows : 

{Revulsives. 
Diaphoretics. 
Baths. 

t-v  f  Purgatives. 

2.  D.gest.ve  system    |  Em*tics 

TT  .  f  Diuretics. 

3.  Lrinary  system  <  ,,•„ 

4.  Respiratory  system — Oxygen. 

„    r-      ,  ,  f  Compression  of  the  carotids. 

5.  C.rculatory  system  |  VeneFsection. 

£.    xt  f  Sedatives. 

6.  Nervous  svstem  <    .        ..     ■ 

(  Anaesthetics. 

f  Premature  rupture  (artificial)  of  the  membranes. 
I  Induced  accouchement. 

7.  Genital  system -J  Active  accouchement. 

I  Forced  accouchement. 

[  Csesarian  operation  post-mortem. 

8.  Various  medications. 

9.  Minor  attentions. 

I  shall  enter  into  the  details  of  these  various  means  and  the 
results  they  have  afforded.  I  shall  only  indicate  the  use  of  the 
best  and  the  most  efficacious  among  them  for: 

A.  Preventive  treatment. 

B.  Curative  treatment. 

C.  Consecutive  treatment. 

A.  Preventive  treatment. — The  necessity  for  watching  for  the  ap- 
pearance of  albumen  in  the  urine  of  the  pregnant  women  is  well 
understood.  The  preventive  treatment  par  excellence  consists  in 
the  milk  diet,  continued  as  long  as  there  is  albumen  in  the  urine. 
Induced  accouchement  will  be  reserved  for  quite  exceptional  cases. 
In  grave,  menacing  cases,  where  plethora  is  clearly  pit-sent,  it  be- 
comes necessary  not  to  hesitate  in  making  a  venesection  of  three 
hundred  to  five  hundred  grammes. 

B.  Curative  treatment. — Among  the  minor  attentions,  a  handker- 
chief should  be  placed  between  the  teeth  to  prevent  biting  the 
tongue.     In  cases  of  exceptionally  grave  eclampsia  the  suspension 


256  Eclampsia. 

of  respiration  for  some  time  may  be  the  cause  of  death.  It  will  be 
well  then  to  attempt  artificial  respiration. 

With  regard  to  curative  treatment  proper,  the  means  to  be  em- 
ployed can  be  grouped  in  six  divisions ;  three  of  capital  importance,  a 
major  therapeutic  tripod,  andthreeof  secondary  importance,  a  minor 
therapeutic  tripod.  The  major  tripod  consists  of  anaesthesia,  of  vene- 
section and  of  uterine  evacuation. 

In  a  general  "way,  we  may  say  that  anaesthesia  should  be  applied 
in  every  attack  of  eclampsia.  It  will  be  obtained  by  the  use  of 
chloral  or  chloroform.  Chloral  should  be  given  in  as  high  a  dose 
as  possible,  10,  14,  16  grammes  in  twenty-four  hours,  and  as  much 
as  possible  by  enema.  Chloroform  will  be  administered  to  com- 
plete anaesthesia  and  in  a  sufficient  dose  to  keep  the  patient  in  a 
state  of  calm. 

Bleeding  will  be  employed  in  plethora,  when  the  convulsions  are 
violent  and  when  the  coma  is  accompanied  by  symptoms  of  as- 
phyxia. According  to  the  case,  there  will  be  removed  five  hundred 
to  one  thousand  grammes,  exceptionally  more. 

"With  regard  to  emptying  the  uterus,  we  seek  to  obtain  this  as 
promptly  as  possible,  but  without  having  recourse  to  violent 
measures.  If  labor  is  not  declared,  spontaneous  contractions  will 
be  awaited,  except  on  special  indications,  when  accouchement  will 
be  induced.  If  dilatation  has  commenced,  forced  accouchement 
will  be  avoided  unless  there  is  present  a  menacing  danger  to  the 
mother,  when  it  will  be  authorized.  As  soon  as  dilatation  is  com- 
plete the  accouchement  must  be  terminated  by  the  forceps  or  by 
version  and  extraction.  The  delivery  of  the  appendages  will  be 
equally  active  within  the  limits  prescribed  by  prudence. 

In  our  minor  tripod  are  placed  purgatives,  diuretics  and  sudorifics. 
It  is  not  necessary  to  discuss  them  as  these  remedies  are  common 
I    general  medicine. 

C.  Consecutive  treatment.  —  The  consecutive  treatment  may  be 
summed  up  in  a  double  indication,  for  one  part,  to  remedy  the  dif- 
ferent complications  which  succeed  to  eclampsia,  for  the  other  to 
prevent  the  return  of  the  disease  by  removing  the  cause  and  adopt- 
ing preventive  therapeutic  means. 


Puerperal  Septicemia.  25? 


CHAPTER  XVI. 


PUERPERAL    SEPTICEMIA. 

It  has  been  reserved  for  Pasteur  to  make  known  the  microbic 

nature  of  the  causal  element  of  this  disease.     The  microbes  met  in 
puerperal  fever  are  of  four  varieties : 

1.  The  bacilli  in  rod-like  forms,  cylindrical  bacteria,  the  cause  of 
rapid  septicaemia. 

2.  The  micrococci  in  chaplet-form,  the  source  of  an  attenuated 
septicamia. 

3.  The  micrococci  in  double  points  (the  diplococcus)  the  cause  of 
suppuration. 

4.  The  micrococci  in  isolate  points,  of  a  role  not  yet  well  es- 
tablished. 

Though  the  respective  part  played  by  each  of  these  varieties  is 
still  unsettled,  their  microbic  influence,  considered  in  a  general  way, 
is  beyond  contest,  so  that  puerperal  septicaemia  is,  without  doubt, 
a  microbic  affection. 

We  have  now  to  see  how  these  microbes  arrive  in  the  feminine 
organism,  that  is,  the  aetiology  of  puerperal  septicaemia.  Let  us 
compare  the  pregnant  woman  to  a  fortified  and  besieged  city;  a 
projectile  produces  a  break  in  the  ramparts,  the  same  as  accouche- 
ment a  series  of  wounds  at  the  genital  surface  of  the  woman.  What 
results  from  this  breach'?  If  the  enemy  be  distant  the  besieged 
will  have  time  to  repair  the  gaps  before  their  arrival,  the  same  as 
during  post-partum,  nature  cicatrizes  the  genital  wounds  against  all 
aggressions  of  the  microbes.  If,  on  the  contrary,  the  enemy  be 
near,  they  attempt  to  penetrate  and  a  sharp  struggle  ensues.  This 
struggle  in  the  breach  represents  the  inflammation  of  the  genital 
wounds  (localized  septicaemia).  If  the  organism  is  victorious,  the 
microbes  are  repulsed,  all  is  confined  to  the  local  septicaemia.  But, 
on  the  contrary,  if  the  assailants  are  successful  the  city  is  invaded, 
the  combat  becomes  general.  In  the  same  way  if  the  microbe  pene- 
trates into  the  economy  its  triumph  causes  the  death  of  the  woman ; 
its  defeat,  cure. 

To  comprehend  this  struggle  we  have  to  examine : 

1.  The  state  of  the  besieged  city  (puerperal  state). 

2.  The  breech  (genital  wounds). 

3.  The  enemy  or  the  assailants  (microbes). 

4.  The  passages  leading  to  the  city  and  into  its  interior 
(mode  of  arrival  and  of  penetration). 


258  Puerperal  Septic<smia>. 

1.  Puerperal  state. — The  modifications  produced  by  puerperality, 
in  particular  in  the  composition  of  the  blood,  are  seen  to  predispose 
to  the  invasion  of  the  septicemic  microbe. 

2.  The  genital  wound  is  multiple  and  composed  of  the  surface  of 
the  placental  insertion,  as  well  as  the  solutions  of  continuity  existing 
in  the  cervix,  the  vagina,  and  the  vulva.  Any  wound  outside  the 
genital  sphere,  notably  those  of  the  nipples,  of  the  skin  (excoriations 
of  the  buttocks,  etc.),  may  lead  to  the  same  results.  Sometimes  the 
penetration  occurs  by  the  urinary  passages  (cystitis,  infectious  ne- 
phritis), notably  in  consequence  of  a  septic  catheterism.  May  the 
microbes  also  enter  by  a  solution  of  continuity  of  the  digestive  and 
respiratory  passage  ?  This  is  possible  but  it  has  not  been  demon- 
strated. 

3.  The  microbes  have  been  previously  described.  Each  sudden 
invasion  that  they  make  into  the  organism  is  marked  by  a  chill. 

4.  Mode  of  arrival  and  of  penetration  : 

a.  Arrival  at  the  organism. — In  a  certain  number  of  cases,  perhaps 
more  frequently  than  has  been  supposed,  the  puerperal  microbes 
are  found  during  pregnancy  in  the  vagina  and  cervical  canal, 
simply  waiting  favorable  conditions  to  multiple  and  penetrate  into 
the  maternal  organism.  This  multiplication  will  be  favored  during 
pregnancy  by  any  local  suppuration  (vaginitis),  by  the  flow  and  the 
stagnation  of  blood  (haemorrhages),  and  after  accouchement,  by  the 
putrefaction  of  debris  retained  in  the  uterus.  Outside  of  these 
cases,  the  carrier  of  the  microbes  to  the  organism  may  be  a  liquid 
(non-sterilized  injection),  or  a  solid  body  (materials  of  dressing,  in- 
jection canula,  obstetrical  instruments,  finger  of  the  attendant,  etc.). 
May  a  gaseous  body,  the  air  for  example,  serves  as  a  carrier  for 
puerperal  microbes?  The  generality  of  obstetricians  admit  that 
transmission  by  the  air  is  impossible.  It  will  be  wise,  however,  to 
act  as  if  contagion  through  the  air  were  possible. 

b.  Penetration  into  the  organism. — The  microbes  penetrate  into 
the  organism  : 

By  way  of  the  blood,  veins  :  phlebitis,  symptoms  of  rapid  generali- 
zation. 

By  way  of  the  lymphatic  vessels  :  lymphangitis,  phlegmon,  aden- 
itis, inflammation  of  the  serous  membranes  (notably  peritonitis). 
Symptoms  of  diffusion  in  general  much  slower,  the  glands  often 
forming  an  impassible  barrier,  such  are  cases  where  the  septi- 
caemia especially  evolves  as  a  local  affection  with  only  slight  general 
reaction. 

In  some  eases  of  puerperal  fever,  it  is  impossible  to  detect  airy 
mode  as  contagion  and  septicaemia  appears  to  be  spontaneous. 
This  is  a  false  interpretation,  the  ways  of  contagion  are  multiple 
and  sometimes  difficult  to   recognize,  and   besides,  contagion  is 


I'll!  rperal  Septica  mia.  259 

possible  by  the  intermediary  of  microbes  remaining  some  time  in 
the  genital  organs. 

Pathological  anatomy  and  symptomatology. — Puerperal  septicemia 
begins  exceptionally  during  pregnancy  or  accouchement,  but  almost 
always  from  the  second  to  the  tenth  day  after  delivery.  It  may 
assume  quite  varied  clinical  forms,  making  its  description  difficult. 
For  clearness  I  shall  adopt  seveu  types,  including  the  principal 
forms  from  which  the  secondary  or  mixed  forms  may  he  derived. 
I  -hall  also  Bpeak  of  some  special  forms  in  terminating. 

1.  Generalised  form  without  lesions. — Acute  non-suppurating  septi- 
cemia.— After  accouchement,  intense  chill  the  following  day  and 
the  day  after.  Rapid  ascension  of  temperature  to  40  to  41  C. 
Great  acceleration  of  the  pulse,  which  soon  becomes  irregular,  im- 
perceptible. Intense  and  progressive  dyspnoea.  Face  pale,  livid, 
sometimes  cynotic,  tongue  red  and  dry.  Abdomen  scarcely  swollen. 
Vomiting  sometimes  marked,  sometimes  wanting.  Black  and  ex- 
tremely fetid  diarrhoea.  Urine  scanty,  very  albuminous.  No  trace 
of  localization.  Acute  terminal  delirium,  sometimes  giving  place  to 
coma  in  the  last  moments.  Death  in  thirty-six  or  forty-eight  hours 
or  in  three  days.  The  autopsy  remains  negative.  Bacteriological 
examination  of  the  blood  alone  demonstrates  the  presence  of  culpa- 
ble microbes. 

Sometimes  in  place  of  this  early  beginning  and  rapid  march, 
fever  appears,  preceded  by  one  or  several  chills,  somewhat  later 
taking  a  certain  analogy  with  that  of  typhoid  fever,  with  sometimes 
an  ataxic  predominence,  sometimes  an  adynamic.  The  patient 
succumbs  in  some  days  in  a  coma  which  has  succeeded  to  delirium, 
or  with  pulmonary  complications. 

2.  Generalized  form  with  lesions. — Acute  suppurative  septicemia. — 
This  form  is  characterized  by  the  formation  of  multiple  abscesses, 
probably  of  venous  origin  (infectious  phlebitis),  which  may  occupy 
any  part  of  the  organism.  The  general  symptoms  exist  alone  in 
the  beginning,  during  a  certain  time,  and  are  then  followed  by 
various  abscesses.  The  appearance  of  the  symptoms  is  later  than 
in  the  acute  non- suppurative  form.  The  initial  chill  scarcely  ever 
occurs  before  the  fifth  day  and  sometimes  not  before  ten  or  fifteen 
days  and  even  more.  This  chill  is  usually  intense  and  prolonged. 
After  this  first  chill,  the  state  does  not  appear  grave,  except  a  fever 
which  presents  great  variations.  But  a  second  and  a  third  chill 
quickly  follow,  usually  violent  and  without  periodicity.  The  general 
state  is  aggravated,  the  skin  is  dry,  the  face  pale,  the  appetite  mil, 
the  tongue  red,  the  thirst  excessive.  Diarrhoea  is  abundant  and 
fetid.  The  urine  is  scanty  and  almost  always  albuminous.  The 
chills  succeed  in  variable  number.     Their  interval  at  the  beginning 


2G0  Puerperal  Septicemia. 

is  marked  by  periods  of  complete  apyrexia.  But  soon  the  fever 
becomes  continuous,  intense  and  contributes  to  the  aggravation  of 
the  general  state.  Thus  far  the  most  attentive  local  examination 
reveals  no  localized  lesion  and,  except  a  slight  painfulness  which 
sometimes  exists  about  the  broad  ligaments,  the  manifestations  of 
the  disease  reveal  no  distinct  state  in  any  organ. 

But  after  a  number  of  days,  which  most  often  vary  from  eight  to 
fifteen  after  the  first  chill,  follows  a  second  period  in  which  multiple 
abscesses  are  shown.  The  suppurations  may  occupy  any  part  of  the 
organism,  I  shall  only  mention  their  seats  of  predilection : 

Genital  organs. — Abscess  of  the  broad  ligament,  the  size  of  a  pea 
to  that  of  an  apple  and  even  more.  Pus  in  the  uterine  sinus  and 
in  the  tubes. 

Nervous  system.  —  Suppuration  of  the  meninges.  Suppurative 
phlebitis  of  the  sinuses.  Abscess  in  the  cerebral  or  medullary 
parenchyma. 

Respirator}/  system. — Purulent  pleurisy.  Infarctus  and  abscess 
of  the  lungs. 

Circulatory  system. — Suppurative  pericarditis.  Ulcerous  endo- 
carditis. Abscess  of  the  cardiac  wall.  Small  phlebitie  or  peri- 
phlebitic  abscess  at  any  point  of  the  body.  Infarctus  and  abscess 
of  the  spleen. 

Digestive  system. — Abscess  of  the  dependent  glands,  notably  the 
liver,  of  which  infarctus  (miliary  abscesses  or  larger)  are  excessively 
frequent. 

Urinary  system. — Besides  the  vesical  complications  are  frequently 
noted  infarctus  and  multiple  abscesses  of  the  kidney,  also  a  peri- 
neal suppuration. 

Regions.  —  Abscesses  of  the  cellular  tissue.  Echars  of  the  pro- 
jecting regions  (trochanter,  sacrum).  Articular  abscess.  Suppuration 
of  the  synovial  tendons.  Abscesses  cf  the  periosteum  and  of  the 
bone  itself. 

These  various  suppurations  are  manifested  by  their  usual  symp- 
toms, hidden  here  in  the  importance  of  the  general  symptoms.  Let 
us  simply  note  icterus  in  the  hepatic  complications  and  the  stetho- 
scopic  phenomena  in  the  pulmonary  complications. 

Cured  cases  are  the  exception;  death  is  the  rule.  It  follows 
under  the  influence  of  the  progressive  poisoning  of  the  organism,  to 
which  the  functional  disorders  caused  by  the  visceral  suppurations 
are  auxiliary. 

3.  Peritonceal  form — peritonitis. — Puerperal  peritonitis  takes  its 
origin  in  the  genital  organs.  Sometimes  it  is  consecutive  to  an  in- 
flammation first  localized  in  the  pelvic  cavity ;  sometimes  it  is 
primary.  This  generalized  peritonitis  is  one  of  the  most  frequent 
forms  of  puerperal  septicemia.  It  is  usually  announced  by  a  violent 
pain  and  an  intense  chill.     The  pain  arises  in  the  uterus  and  soon 


Puerperal  Septicemia.  261 

radiates  to  all  the  abdomen  with  progressive  swelling.  The  patient 
lies  on  the  back,  immobile,  s<  ae  noi  to  increase  her  sufferings.  The 
face  shows  the  pain  and  takes  that  special  expression  met  in  peri, 
tonaeal  affections.  The  tongue  is  dry,  the  thirst  acute,  the  hiccough 
almost  continual,  the  vomiting  incessant,  first  alimentary,  then 
bilious.  Diarrhoea  is  the  rule  and  in  contrast  with  the  usual  con- 
stipation of  non-puerperal  peritonitis. 

Respiration  becomes  difficult,  and  the  dyspnoea  seems  to  inert 
in  proportion  to  the  distention  of  the  abdomen.     The  fever  i>  high, 
the  pulse  frequent,  the  lochia  is  little  abundant  and  usually  fetid. 
The  lacteal  secretion  dries  up,  or,  if  not  yet  established,  it  is  not 
produced  at  all. 

Cure  may  take  place,  when  the  disease  is  vigorously  combatted 
at  the  onset,  then  the  symptoms  progressively  diminish.  But  the 
most  usual  termination  is  in  death,  which  follows,  either  under  the 
influence  of  the  progressive  asphyxia  due  to  the  poisoning  of  the 
whole  organism  and  to  the  distention  of  the  abdomen,  or  under  the 
influence  of  the  extension  of  the  inflammation  to  the  pleura  and  to 
the  pericardium. 

The  lesions  found  in  the  autopsy  are  those  of  suppurative  peri- 
tonitis. 

4.  Periuterine  form — pelvic  peritonitis. — Phlegmon  of  the  broad  lig- 
ament.— In  proportion  as  we  advance  in  this  description,  we  see  the 
septicaemia  become  more  and  more  localized  and  its  gravity  de- 
crease. In  fact,  the  more  septicaemia  becomes  localized,  the  better 
is  its  prognosis. 

Chills  followed  by  fever  and  pain  are  the  symptoms  which,  here, 
as  in  peritonitis,  open  the  scene,  but  their  intensity  is  less  than  in 
this  last  disease. 

The  general  symptoms  are  nearly  the  same  in  pelvic  peritonitis 
and  in  phlegmon  of  the  broad  ligaments  and  may  be  resumed  in  a 
febrile  state,  more  or  less  marked  in  relation  with  the  gravity  of  the 
local  conditions,  but  the  progress  of  these  affections  is  essentially 
different  and  requires  separate  description. 

a.  Pelvic  peritonitis  is  manifested  by  a  swelling  at  the  posterior 
cul-de-sac  of  the  vagina.  There  is  constituted  at  this  point  a  tumor 
which  pushes  the  uterus  forward  and  upward.  If  resolution  occurs 
this  tumor  takes  a  harder  consistency  and  becomes  progressively 
smaller  and  more  indurated.  If  suppuration  takes  place  the  tumor 
increases  in  volume  and  in  place  of  induration  fluctuation  is  found. 
This  abscess,  encysted  by  false  membranes,  may,  exceptionally,  be 
absorbed.  More  often  it  opens  into  the  vagina  or  rectum,  or  into 
the  peritonaeum.  Opening  into  the  vagina  or  rectum,  whether  arti- 
ficial or  natural,  lead  to  cure  at  the  end  of  a  variable  time.  The 
opening  of  the  pus  into  the  peritonaeum  causes  a  general  peritonitis, 
quickly  fatal  in  a  majority  of  cases. 


262  Puerperal  Septicemia. 

b.  Phlegmon  of  the  broad  ligaments. — This  phlegmon  is  usually 
unilateral,  and  more  often  on  the  left  than  on  the  right.  It  forms  a 
tumor  analogous  to  that  of  pelvic  peritonitis  but  occupies  the  lateral 
cul-de-sac,  pushing  the  uterus  toward  the  healthy  side.  Eesolution 
may  occur  by  induration  and  progressive  diminution,  or  by  suppu- 
ration. The  abscess  may  be  capable  of  opening  into  the  rectum, 
vagina,  peritonaeum,  or  bladder.  The  suppuration  may  also  open 
externally  through  the  abdominal  wall. 

5.  Uterine  form — metritis. — Uterine  septicaemia  or  septic  metritis, 
begins  by  pain  and  elevation  of  temperature,  but  usually  the  initial 
chill  is  wanting.  The  pain  is  very  acute  and  at  first  simulates  that 
of  peritonitis.  But  it  is  localized  in  the  subumbilical  region  of  the 
abdomen  and  it  is  only  pressure  on  the  uterus  that  aggravates  it. 
This  metritis  may  give  rise  to  a  contiguous  inflammation,  even  to 
a  generalized  peritonitis,  but  usually,  especially  when  properly 
treated,  it  terminates  in  resolution,  or  degenerates  into  a  chronic 
parenchymatous  metritis. 

The  general  state  is  usually  but  slightly  affected.  The  fever  is 
moderate,  the  temperature,  aside  from  complications,  rarely  passes 
39-  C.     Cure  is  the  rule. 

6.  Vulvo-vaginal  form — vulvo-vaginitis. — After  delivery,  especially 
from  the  third  to  the  fifth  day,  there  is  often  found  on  the  internal 
surface  of  the  labia  and  on  the  terminal  portion  of  the  vagina 
grayish  surfaces  of  gangrenous  aspect,  like  exudates  of  diphtheritic 
appearance,  to  which  has  been  given  the  name  vulvar  or  vaginal 
eschars.  These  eschars  are  only  the  local  manifestation  of  puer- 
peral septicaemia. 

In  some  cases  they  are  not  accompanied  by  any  general  reaction, 
and,  under  the  influence  of  local  care,  the  exudation  disappears 
and  cicatrization  occurs  without  accident. 

But  in  other  cases  they  become  the  origin,  exceptionally,  of  phle- 
bitis, more  often  of  a  lymphangitis,  which  induces  adenitis  of  the 
inguinal  glands,  causing,  by  propagation,  phlegmon  of  the  iliac  fossa 
and  even  peritonitis.  The  septicaemia  then  becomes  general  and 
assumes  an  increasing  gravity. 

7.  Mammary  form — mastitis. — As  at  the  vulva,  septicaemia  may  re- 
main absolutely  local  or  extend  to  more  or  less  distant  parts.  Local 
it  is  manifested  in  the  form  of  fissures,  generally  situated  at  the  base 
of  the  nipple.  These  fissures  are  deep  and  covered  by  a  grayish 
coating.  From  the  nipple  the  septicaemia  may  follow  different  ways 
to  reach  the  gland-producing  abscess  of  the  breast,  or  it  may  reach 
the  axillary  region  by  the  lymphatics,  producing  adenitis,  and  pass- 
ing this  point  may  cause  general  septicaemia,  though  the  last  is 

'fly  ever  observed. 
In   the   great  majority  of   cases  the  mammary  septicaemia  is 


Puerperal  Septica  mia, 

confined  to  the  Lesions  of  the  nipple  and  of  the  mammas,  with  a 
genera]  reaction  in  relation  with  these  local  accidents. 

8.  Special  forms. — a.  Cystitis  and  nephritis. — This  form  of  puerperal 
Bepticaamia  is  rare.  During  pregnancy  or  after  delivery,  in  con- 
fluence of  a  septic  catheterism,  a  cystitis  is  declared;  the  inflam- 
mation follows  the  ureter  to  the  kidney,  an  infectious  nephritis  is 
the  result,  and  is  manifested  by  it,  usual  symptoms.  This  nephritis 
may  be  the  cause  of  puerperal  convulsions. 

/>.  Phlebitis  of  the  lower  limbs. — This  phlebitis  is  generally  known 
as  phlegmasia  alba  dolens.  It  presents  two  forms,  especially  dif- 
ferent in  their  initial  period. 

The  first  generally  begins  about  the  fifteenth  day  of  post-partum, 
when,  since  accouchement,  the  apyrexia  has  been  complete  and  the 
condition  as  satisfactory  as  possible.  At  tins  moment  there  occur 
a  moderate  fever  and  a  pain  in  the  iliac  fossa  or  in  the  calf  of  the 
leg.  Then  the  phlegmasia  runs  its  course  and  lasts  from  one  t<» 
three  months. 

The  second  succeeds  to  other  septicemic  manifestations,  fever 
and  chills,  onset  of  peritonitis,  etc.  The  various  symptoms  appear 
three  to  six  days  after  aceouchemeut  and  at  first  no  clear  locali- 
zation can  be  found,  then,  the  phlebitis  is  declared  and  the  septi- 
caemia becomes  localized  in  the  veins  of  the  lower  limbs. 

c.  Paralyses. — Besides  paralyses  occurring  during  the  puerperal 
state,  under  the  influence  of  causes  independent  of  that  state,  and 
not  including  pareses  of  the  lower  limbs,  which  result  from  compres- 
sion during  accouchement,  there  exist  hemiplegias  and  paralyses 
still  incompletely  understood  and  which  appear  of  septicemic  na- 
ture.    Their  prognosis  is  in  general  benign. 

d.  Puerperal  eruptions. — Besides  the  eruptions  independent  of  the 
puerperal  state,  there  is  sometimes  seen  after  delivery  erythe- 
matous plaques,  the  confluence  of  which  recalls  the  aspect  of  the 
skin  in  scarlatina.  This  eruption  seems  to  be  a  simple  cutaneous 
manifestation  of  puerperal  septicaemia. 

Prognosis. — The  gravity  of  the  prognosis  will  vary  : 

With  the  form  of  the  disease ;  the  more  localized  the  septicaemia 
the  better  its  prognosis. 

With  the  period  of  its  beginning;  in  general  the  prognosis  is 
better  in  proportion  as  the  onset  is  distant  from  the  moment  of 
accouchement. 

With  the  intensity  of  the  fever ;  the  more  pronounced  the  thermic 
elevation,  the  more  grave  is  the  prognosis. 

With  the  surroundings  of  the  patient ;  if  the  case  is  isolated  it  has 
more  chance  of  beim?  benign.  In  a  series  of  successive  contagions, 
the  poison  appears  to  gain  intensity. 


264  Puerperal  Septicemia. 

With  the  treatment ;  the  majority  of  cases  of  septicaemia  (except 
those  generalized  at  first),  well  treated,  should  be  cured. 

Treatment. — So  far  as  prophylactic  treatment  is  concerned  it  will 
be  understood  that  the  antisepsis  must  be  perfect  in  relation  to  the 
attendants,  physician  and  nurse,  to  the  instruments,  and  to  all  the 
surroundings  of  the  patient. 

With  regard  to  the  post-partum  three  circumstances  may  present 
— the  normal  state,  a  menace  of  septicaemia,  and  finally  a  fully 
established  septicaemia. 

1.  Normal  state. — Vulvar  toilets  are  sufficient  unless  there  is 
reason  to  doubt  the  ascepticism  of  the  genital  organ,  when  vaginal 
injections  will  be  necessary,  one  to  two  a  day,  with  a  carbolic  (1-50) 
or  a  boracic  (3-100)  solution.  These  injections  should  be  given  by 
the  physician  or  by  an  intelligent  nurse  who  understands  how  to 
avoid  the  penetration  of  air. 

2.  Menacing  septicemia. — Whenever  we  have  present : 

Retention  of  a  portion  of  the  appendages  (placenta, 

ovuline  membranes) ; 
Cephalalgia ; 
Fetidity  of  the  lochia. 

It  is  necessary  to  fear  the  appearance  of  septicaemia  and  to  take 
measures  to  prevent  its  development.  In  such  cases  frequent 
vaginal  injections  will  be  given,  two  to  four  in  twenty-four  hours, 
with  one  to  two  litres  of  a  carbolic  solution,  1-50. 

If  the  lochia  is  fetid  and  if,  in  spite  of  repeated  vaginal  in- 
jections, the  odor  persists,  it  is  necessary  to  have  recourse  to  intra- 
uterine injections,  repeated  twice  a  day  until  the  normal  state 
returns. 


Fig.  303. — Budin's  intra-uterine  sound. 

3.  Declared  septicemia. — As  soon  as  septicaemia  is  declared,  that 
is,  after  the  appearance  of  the  chills  and  of  the  fever,  the  treatment 
is  nearly  the  same  in  all  forms,  except  the  mammary,  which  is 
usually  slight,  only  requiring  local  care,  and  except  the  special  forms 
which  will  not  be  taken  into  consideration  here. 

The  indication  is  threefold  :  To  clear  the  genital  surface  of  mi- 
crobes, genital  medication ;  to  prevent  the  penetration  of  microbes 
into  the  organism,  abdominal  medication;  to  aid  the  organism  in 
its  struggle,  general  medication. 


I'm  >■]><  ral  Septica  mia. 


265 


Qenital  medication.— h\  cases  where  the  septicaemia  is  clearly  of 
vulvar  origin,  we  may  be  content  with  vulvar  and  vaginal  lava{ 
repeated  two  to  four  times  a  day,  with  carbolic  acid,  L-50,  or  with 
bichloride  of  mercury,  1-2000,  and  with  dusting  the  vulva  with 
iodoform.  But  most  often  intra-uterine  asepsis  must  be  assured  by 
the  use  of  injections  into  the  cavity  of  the  uterus.  The  importance 
of  this  uterine  toilet  is  capital  and  merits  emphasis.  I  shall  suc- 
cessively describe  the  classic  intra-uterine  injection  and  then  the 
improvements  that  I  believe  are  necessary  to  give  this  injection  its 
requisite  efficacy,  the  perfected  intra-uterine  injection. 


Fig.  304. — Metallic  basin  for  abundant  vaginal  irrigation. 

Classic  intra-uterine  injection. — The  best  intra-uterine  sound  for 
this  purpose  is  that  recommended  by  Budin  (Fig.  303).  The  woman 
is  left  in  her  usual  position,  a  basin  (Fig.  304)  is  slipped  under  the 
buttocks.  This  basin  is  provided  with  a  discharge  tube  which 
permits  a  prolonged  injection.  After  having  cleansed  the  vulva 
and  vagina  the  extremity  of  the  sound,  previously  dipped  in  vaseline, 
is  directed  on  the  finger  of  one  hand  through  the  vagina  to  the 
external  orifice  of  the  uterus.  From  this  moment  the  instrument  is 
pushed  in  the  supposed  direction  of  the  uterine  canal.  When  the 
sound  has  passed  the  external  orifice  it  meets  at  three,  four,  or  five 
centimetres  a  first  obstacle,  which  is  the  internal  orifice  in  the 
process  of  reformation.  The  obstacle  is  constituted  less  by  the 
narrowness  of  the  orifice  than  by  the  angle  formed  by  the  uterine 
wall  (Fig.  305).  After  this  obstacle  a  second  is  met,  some  centi- 
metres farther ;  this  is  the  uterine  circle,  and  when  it  is  passed  the 
sound  penetrates  to  the  fundus  of  the  uterus  without   difficulty. 


266  Puerperal  Eclampsia. 

When  the  sound  has  penetrated  to  the  fundus  a  variable  quantity 
of  liquid  is  allowed  to  flow  through  it.  It  is  well  to  use  several 
litres  of  an  antiseptic  solution  (ten  to  twenty  litres). 


Fig.  305. — Post-partum  uterus  and  vagina.     CU,  uterine  circle:  OI,  internal 
orifice;  O  E,  external  orifice. 

The  perfected  intra-uterine  injection. — Against  the  classic  intra- 
uterine injection  three  objections  may  be  urged: 

1.  It  is  often  difficult  to  introduce  the  sound  on  account  of  the 
obstacles  created  by  the  internal  orifice  and  by  the  uterine  circle. 
Sometimes  it  is  even  impossible  to  introduce  it.  Thus  many  phy- 
sicians, even  though  experienced,  find  it  impossible  to  penetrate 
beyond  the  internal  orifice  or  the  uterine  circle. 

2.  The  curved  direction  of  the  genital  canal,  incompletely  cor- 
rected by  the  sound,  obstructs  the  return  of  the  liquid. 

3.  The  simple  contact  of  the  liquid  alone  is  not  sufficient  to  com- 
pletely cleanse  the  uterine  surface,  the  friction  of  a  solid  body  is 
indispensable  for  this  effect. 


/^ 


Fig.  306. — Irrigating  curette. 

To  remedy  these  disadvantages  I  use  an  irrigating  curette  (Fig. 
306)  perforated  through  its  length  by  a  canal  which  allows  the  use 


Puerperal  Septicemia.  26*3 

of  an  antiseptic  liquid.  The  terminal  ring  i-  -harp  on  one  side, 
blunt  on  the  other.  The  malleability  of  the  instrument  allow-  it  to 
he  curved  at  will.     To  use  this  irrigating  curette  in  the  cleansi] 

the  uterine  canal,  I  proceed  as  follows : 

The  patient  being  placed  in  the  obstetrical  position,  alter  a  vulvar 
and  vaginal  toilet,  I  grasp,  under  guidance  of  the  index  Qnger,  the 
anterior  lip  of  the  cervix,  and,  if  necessary,  the  posterior,  with 
a  vulsellum.  The  uterus  is  then  lowered  by  drawing  on  the 
vulsellum  and  by  having  an  assistant  support  the  fundus  through 
the  abdomen.  The  irrigating  curette  is  now  introduced  into  the 
uterus  by  guiding  it  with  the  finger.  According  to  the  intensity  of 
the  curetting  that  is  desired,  the  uterine  surface  is  scraped,  from 
above  downward,  with  the  blunt  side  or  with  the  sharp  side  of  the 
instrument.  A  tour  of  the  uterine  cavity  is  thus  made  and  then  the 
cervix  is  treated  in  the  same  way.  In  terminating,  a  large  quantity 
of  liquid  (two  to  three  litres)  is  allowed  to  flow,  without  withdrawing 
the  curette,  to  complete  the  cleansing  of  the  uterine  cavity  and  to 
insure  the  exit  of  all  the  detached  debris. 

Made  in  this  way,  uterine  cleansing,  besides  securing  complete 
asepsis,  presents  a  double  advantage : 

First,  that  of  facilitating  the  penetration  of  the  instrument  to  the 
fundus  of  the  uterus,  for  in  drawing  on  the  cervix  the  curve  of  the 
uterine  canal  is  straightened  (Fig.  308). 


Fig   30S. — Uterus  drawn  to  the  vulva  by  the  use  of  the  vulsellum. 
C  L",  uterine  circle;  O  I,  internal  orifice. 

Second,  that  of  facilitating  the  return  of  the  liquid  and  thus  pre- 
venting its  penetration  into  the  peritonaeum  through  the  tubes.  The 
same  mechanism  which  so  easily  allows  the  entrance  of  instrument 
removes  all  obstacles  to  the  reflux  of  the  liquid. 

The  classic  intra-uterine  injection,  copiously  given,  will  suffice  in 
a  certain  number  of  cases,  but  I  believe  it  more  prudent  to  have 
recourse  at  once  to  the  perfected  intra-uterine  injection  that  I  have 
described. 

Abdominal  medication.  — Two  measure?-,  ice  on  the  abdomen  or  a 
large  vesicatorv. 


268  Puerperal  Septicaemia. 

The  ice  is  preferable.  It  is  enclosed  in  a  rubber  bag  and  applied 
on  the  abdomen  by  interposing  a  double  layer  of  flannel,  to  avoid 
echars  from  freezing.  The  sack  is  kept  in  place  by  a  belt  around 
the  abdomen.     The  ice  should  be  changed  every  two  or  three  hours. 

A  large  vesicatory  will  replace  the  ice  in  cases  of  necessity. 

The  ice,  by  lowering  the  temperature  of  the  genital  organs,  retards 
the  multiplication  of  the  germs  and  impedes  their  penetration  into 
the  organism.  Besides,  it  is  a  powerful  sedative  against  the  ab- 
dominal pain. 

The  vesicatory  acts  in  the  same  way  by  the  revulsion  that  it  causes. 
But  its  action  is  less  salutary  and  less  complete. 

Leeching  and  cupping  has  been  advised  in  some  cases. 

General  medication. —  Tonics  and  antithermics  are  the  two  princi- 
pal indications.  The  best  tonics  are  alcohol,  milk,  if  tolerated,  and 
ether  in  subcutaneous  injections,  in  cases  of  collapse.  As  anti- 
thermics, sulphate  of  quinine  (1  gramme  to  1.5  gramme)  and  anti- 
pyrine  (1  to  2  grammes)  are  administered. 

I  do  not  speak  of  the  special  indications  which  may  occur  in 
consequence  of  the  formation  of  purulent  collections  (suppuration 
of  the  broad  ligaments  of  the  iliac  fossae,  etc.).  Local  treatment 
will  be  the  same,  then,  as  in  suppuration  of  these  regions  produced 
by  causes  other  than  puerperal  septicaemia. 


Extra-Genital  Diseases.  269 


CHAPTER  XVII. 


PUERPERAL  PATHOLOGY.— EXTRA-GENITAL 
LOCALIZED   DISEASES. 

A.  Nervous  system. — A  passing  delirium  sometimes  occurs  during 
labor  if  it  is  painful  or  prolonged.  This  disturbance  of  the  cerebral 
function  is  due,  without  doubt,  to  the  intensity  of  the  painful  phe- 
nomena.    It  disappears  after  accouchement. 

Under  the  influence  of  the  puerperal  state,  much  more  often  after 
delivery  than  during  pregnancy,  there  is  observed  a  veritable 
insanity  (mania  or  melancholia),  of  a  variable  prognosis,  and  which 
may  persist  after  the  cessation  of  the  puerperal  state.  Mania  is 
sometimes  the  consequence  of  eclampsia.  Septicaemia  does  not  ap- 
pear to  play  any  pathological  role  here.  It  has. been  pretended  that 
pregnancy  may  exercise  a  fortunate  influence  on  an  already  existing 
mania.  Alienation  of  puerperal  cause  does  not  require  any  special 
treatment.  There  exists  no  indication  to  provoke  abortion  or  pre- 
mature accouchement. 

Various  neuralgias,  notably  odontalgia,  are  produced  or  aroused 
by  pregnancy.  Treatment :  to  avoid  any  operation  on  the  teeth 
during  gestation;  general  or  local  narcotics. 

Lumbo-abdominal  neuralgia  is  especially  manifest.  It  is  due  to 
the  uterine  contractions.  Treatment :  laudanum  or  viburnum,  in- 
ternally; morphine  in  subcutaneous  injections. 

Women  often  complain  of  cramps  in  the  calves  of  the  legs. 
During  pregnancy  the  pains  in  these  regions  are  due  to  the  venous 
distention,  and  are  relieved  by  the  horizontal  position  or  by  gradual 
compression.  During  accouchement  these  pains  sometimes  take  a 
great  intensity,  and  are  caused  by  the  compression  of  the  nerves 
supplying  these  regions.  An  energetic  massage  is  the  only  means 
of  producing  some  relief. 

Hemiplegias,  paraplegias,  paralyses,  or  partial  pareses,  may  be 
observed  during  pregnancy,  due  to  their  usual  causes,  and  more 
often  to  hemorrhages  of  the  nervous  system  than  to  albuminuria. 

The  influence  of  the  puerperal  state  on  hysteria  is  variable  ac- 
cording to  the  woman.  Hysterical  attacks  are,  fortunately,  rare 
during  labor,  for  they  singularly  disturb  the  period  of  expulsion  and 
of  delivery  of  the  appendages.  In  hysterical  subjects  hypnotism 
might  be  employed  during  the  period  of  dilatation.  During  ex- 
pulsion it  would  be  useless  and  sometimes  dangerous. 


270  Extra-Genital  Diseases. 

Epilepsy,  although  variously  influenced  by  pregnancy,  is  most 
often  benefited.  The  treatment  by  bromide  of  potassium,  even  in 
strong  doses,  is  advised,  for  it  presents  no  danger  to  the  foetus. 

Chorea  may  appear  or  reappear  during  pregnancy.  Usually  it 
persists  to  the  moment  of  accouchement,  when  it  assumes  a  great 
intensity.  It  most  often  ceases  after  labor.  During  pregnancy  it 
should  be  treated  by  chloral,  by  bromide  of  potassium  and  by 
morphine.  During  labor,  chloroform  should  be  given  to  quiet  the 
convulsions,  in  case  of  need.  In  some  cases  of  grave  chorea,  digital 
dilatation  of  the  cervix  or  induced  expulsion  will  be  indicated. 

B.  Respiratory  system. — Bronchitis  with  a  particularly  tenacious 
cough  may  favor  or  determine  abortion.  It  requires  the  usual 
treatment. 

Pneumonia,  occurring  during  pregnancy,  causes  premature  ex- 
pulsion in  about  one-half  the  cases.  The  prognosis  for  the  mother 
and  for  the  pregnancy  is  serious  in  proportion  as  gestation  is  ad- 
vanced. It  is  impossible  to  say  whether  the  premature  expulsion 
of  the  ovum  exercises  a  favorable  or  an  unfavorable  influence  on  the 
disease.  The  treatment  should  be  the  same  as  when  pneumonia 
occurs  without  pregnancy.  Antimonium  may  cause  expulsion  of 
the  ovum,  or  contribute  to  the  expulsion,  but  the  gravity  of  the 
prognosis  relegates  this  consideration  to  a  secondary  consideration. 
If  the  woman  is  in  labor,  accouchement  should  be  terminated  as 
promptly  as  possible. 

Pleurisy  rarely  exercises  an  unfortunate  influence  on  the  course 
of  pregnancy  and  this  disease  does  not  seem  to  be  aggravated  by 
the  existence  of  the  puerperal  state.  The  treatment  is  the  same  as 
if  pregnancy  did  not  exist. 

C.  Circulatory  system.  —The  heart,  under  the  influence  of  preg- 
nancy and  of  accouchement,  is  subject  to  overwork  which  produces 
an  hypertrophy  of  the  left  side  and  a  dilatation  of  the  right  side. 
Now,  if  this  organ  was  diseased  previous  to  conception,  grave  dis- 
orders may  result.  The  puerperal  state  may  be  the  cause  of  two 
varieties  of  cardiopaths :  One,  acute  endocarditis,  almost  always 
occurs  during  the  post-partum  and  is  only  a  localization  of  puer- 
peral septicaemia;  the  other,  subacute  or  chronic  endocarditis, 
resulting  from  pregnancy,  terminates  in  the  definite  formation  of  a 
valvular  lesion.  Besides  these  two  varieties,  the  puerperal  state 
causes  myocarditis  exceptionally,  and  fatty  degeneratte  frequently. 

Disease  of  the  heart  quite  frequently  causes  abortion  or  premature 
delivery-  The  frequency  of  this  premature  expulsion  varies  ac- 
cording to  the  following  results  obtained  by  Porak : 


Frequency  of  Premature  Expulsion. 

Maternal  Mortality, 

Aortic  lesions 

25  per  100 

23  per  100 

Mitral  lesions 

42      "           -       - 

-        45       " 

Complex  lesions 

43        "              - 

50       " 

Extra-Genital  Diseases.  '271 

Treatment. — Preventive:  For  a  cardiopath,  dissuasion  from  mar- 
riage ;  it'  married,  do  children  ;  if  children,  no  lactation.  Curative  : 
The  ordinary  medical  treatment,  digitalis,  milk,  diuretics,    in  grave 

cases,  provoked  abortion  or  premature  delivery  may  be  indicated. 

The  peripheral  circulatory  system  is  subject  to  varices  in  one- 
quarter  of  the  primiparffl  and  one-half  of  the  multipara-.  They 
sometimes  begin  with  pregnancy,  but  are  especially  marked  toward 
the  middle  or  toward  the  end.  The  obstruction  of  the  circulation 
produced  by  the  development  of  the  uterus,  the  augmentation  in 
the  quantity  of  blood  during  pregnancy  and  perhaps  a  reflex  action 
arising  from  the  uterus,  explain  their  production. 

When  the  child  succumbs  during  the  course  of  pregnancy,  the 
varices  are  effaced  (Budin,  Rivet).  This  is  an  interesting  sign  of 
the  death  of  the  foetus.  Among  the  complications  may  be  noted 
cedema,  eczema,  ulceration,  phlebitis,  and  finally,  rupture,  which 
may  give  rise  to  fatal  haemorrhage.  Treatment :  Repose  in  the 
horizontal  position ;  moderate  compression  with  an  elastic  bandage. 

The  cervix  or  the  vagina  may  become  varicose  but  the  vulva  is 
the  favorite  seat  of  varices.  The  varices  often  rupture  sponta- 
neously, or  in  consequence  of  a  traumatism,  and  give  rise  to  grave 
haemorrhages.  Treatment:  Horizontal  repose.  Slight  compression. 
In  case  of  rupture,  digital  compression,  forci- pressure,  ligature. 

Haemorrhoids  seem  independent  of  the  varices  of  the  lower  limbs 
and  of  the  genital  organs.  They  are  observed  during  pregnancy 
when  the  constipation  is  obstinate.  Treatment :  Laxatives,  repose, 
baths,  cold  cataplasms,  sedative  suppositories,  exceptionally  surgical 
dilatation  of  the  anal  sphincter. 

Phlegmasia  alba  dolens. — Under  this  term  has  been  designated 
venous  coagulation  of  the  lower  limbs.  The  cause  is,  as  we  have 
seen  in  studying  puerperal  fever,  sometimes  a  septicaemic  phlebitis, 
sometimes  a  phlebitis,  of  an  undetermined  nature,  but  which  seems, 
however,  not  to  be  related  to  septicaemia.  Whiteness,  hardness,  and 
painfullness,  are  the  three  characters  of  the  cedema  produced  by 
this  affection.  The  onset  usually  takes  place  about  the  fifteenth 
day  of  post-partum.  The  duration  is  from  one  to  three  months. 
The  length  of  the  disease  is  due  to  the  coagulation  of  the  blood,  the 
clots  absorbing  slowly.  It  is  very  important  to  keep  the  patient  in 
a  recumbent  position  until  the  resorption  and  the  disappearance  of 
the  clots,  on  account  of  the  danger  of  pulmonary  cedema  and  of 
sudden  death.  Treatment :  In  the  beginning,  quinine  or  anti- 
pyrine  against  the  febrile  element ;  vesicatory  on  the  painful  points 
of  the  lower  limbs ;  to  place  the  limb  in  a  trough  and  envelop  it  in 
compresses  soaked  in  a  borated  solution;  to  replace  the  moist 
dressing  by  a  dry  dressing  (simple  wrapping  with  cotton)  as  soon 
as  the  inflammation  has  disappeared,  recognized  by  the  cessation 
of  the  pain  and  fever ;  to  keep  the  patient  in  a  horizontal  position 


272  Extra-Genital  Diseases. 

until  the  danger  from  embolism  lias  passed.  The  limb  should  be 
enclosed  in  an  elastic  bandage  for  about  six  months,  or  more  if 
swelling  follows  when  it  is  removed. 

D.  Digestive  system. — Pregnancy  sometimes  produces  abundant 
salivation  which  is  observed  especially  at  the  beginning,  and  which 
is  rebellious  to  all  treatment,  except  to  atropine  in  the  dose  of  a 
milligramme. 

Gingivitis  occurs  by  preference  in  the  second  month  of  pregnancy. 
Care  should  be  taken  with  the  cleansing  of  the  mouth  and  there 
should  be  applied  on  the  free  border  of  gums  a  solution  composed 
of  equal  parts  of  spirits  of  cochlearia  and  of  hydrate  of  chloral. 

The  vomiting  of  pregnancy  becomes  grave  when  it  is  capable  of 
altering  the  general  health  of  the  woman.  It  is  incoercible  when  it 
resists  the  greater  part  of  the  usual  methods  employed  to  oppose 
them.  A  great  number  of  procedures  have  been  tried  against  in- 
coercible  vomiting,  sometimes  in  vain,  sometimes  with  success,  so 
that  it  is  impossible  to  be  exclusive.  It  is  necessary  to  attempt,  in 
turn,  all  the  means  advised  until  the  efficacious  agent  is  found,  and 
if  all  fail  to  have  recourse  to  the  uterine  treatment  I  shall  indicate 
in  terminating.  It  is  important  to  distinguish  the  cases  where 
there  exists  with  pregnancy  an  affection  capable  of  determining 
the  incoercible  vomiting  from  those  in  which  all  special  etiological 
ideas  are  wanting. 

When  there  exists  a  casual  disease  the  appropriate  treatment  will 
be  directed  to  its  removal.  When  there  exists  no  appreciable  cause 
the  procedure  then  consists  in  successively  attempting  the  various 
means  enumerated  as  follows : 

1.  Various  remedies. — Variation  in  the  aliments.  Alcohol.  Alka- 
lies. Ice  internally.  Milk  diet.  Purgatives.  Emetics.  Bismuth. 
Iodide  or  bromide  of  potassium.  Valerianate  of  cerium.  Oxalate 
of  cerium.  Lavage  and  gavage  of  the  stomach.  Nutritive  enemas. 
Forced  journeys. 

2.  Sedatives. — Opiates.     Hydrochlorate  of  cocaine.     Hydrate  of  * 
chloral. 

3.  Excitants. — Inhalations  of  oxygen.     Electricity. 

4.  Revulsives. — Ether  spray  over  the  stomach.  Ice  on  the  epi- 
gastrium,  or  on  the  spine.  Vesicatory  or  leeches  on  the  epigastric 
region. 

5.  Uterine  treatment. —  (a)  Applications  to  the  cervix  of  belladonna, 
of  cocaine,  of  leeches.  Cauterizations  of  nitrate  of  silver  or  with 
the  thermo-cautery.  (b)  Digital  dilatation  of  the  cervix  by  Coper- 
man's  method.  The  finger  is  introduced  into  the  cervix  to  the  in- 
ternal orifice,  that  is  opened;  then  attempt  is  made  to  dilate  the 
cervix  by  a  circular  movement  of  the  finger,  and  to  detach  the  mem- 
branes as  far  as  possible.     Tins  method  should  only  be  attempted 


Extra-Genital  Diseases. 


278 


if  the  preceding  means  fail,  as  it  may  cause  abortion  or  premature 
labor,  (c)  Abortion  and  induced  accouchement.  Finally,  in  casee 
resisting  all  therapeutic  measures  ami  where  life  is  threatened,  we 
should  have  recourse  to  the  induction  of  abortion  or  of  accouchemenl 
by  employing  the  measures  that  will  be  indicated  later. 

( ■onsHpation  is  the  rule  during  pregnancy.  This  will  be  combatted 
by  the  usual  means,  avoiding  all  energetic  and  drastic  purgatives. 
Diarrhoea  is  the  exception;  however  it  may  become  incoercible  in 
some  cases  and  determine  abortion  and  even  the  death  of  the 
patient,  without  the  autopsy  revealing  any  lesion  of  the  intestine 
that  explains  the  gravity  of  the  disease. 


FiG.  309. — Test  for  albumen  with  nitric  acid. 

E.  Appendages  of  the  digestive  system. — Hypertrophy  of  the  thyroid 
is  the  rule  during  pregnancy.  It  diminishes  after  accouchement 
without  resuming  its  former  dimensions.  Fatty  degeneration  of 
the  liver  is  also  the  rule  during  pregnancy.  Simple  icterus  may 
cause  the  death  of  the  foetus  or  its  premature  expulsion.  Grave 
icterus  occurs  with  its  usual  symptoms.  Pregnancy  by  the  retard- 
ation that  it  imposes  on  combustion  is  also  a  great  cause  of  hepatic 
colic. 

F.  Urinary  system. — Albuminuria  is  not  a  disease  but  a  symptom 
constituted  by  the  presence  of  albumen  in  the  urine.  Its  importance 
in  the  puerperal  state  is  considerable  on  account  of  its  frequency 
and  of  the  danger  of  eclampsia  that  it  threatens.  Albuminuria  is 
recognized  by  the  examination  of  the  urine.  Among  the  different 
means  of  detecting  its  presence,  we  have  the  nitric  acid  test,  which 


274 


Extra-Genital  Diseases. 


is  expeditious  but  not  sensitive  (Fig.  309) ;  heat  and  nitric  acidy 
which  is  more  certain  (Figs.  310  and  311),  and  Esbach's  procedure. 
In  the  last  method  the  reagent  intended  to  precipitate  the  albumen 
is  a  mixture  of  nine  volumes  of  picric  acid  with  one  volume  of 
acetic  acid.  A  tube  specially  graduated  (Fig.  312  a)  is  filled  with 
urine  to  U,  and  with  the  reagent  to  E.  The  mixture  is  made  by 
closing  the  tube  with  the  thumb  and  shaking.  The  tube  is  finally 
closed  with  a  rubber  cork  and  left  for  twenty-four  hours.  At  the 
end  of  this  time  the  lower  graduation  allows  us  to  read  the  quantity 
of  albumen  deposited  (Fig.  312  b)  indicating  the  amount  contained 
in  a  litre  of  urine. 


Fig.  2ii. — Test  for  albumen  by  the  use  of  heat. 


Fig.  310. 


Albuminuria,  either  directly  or  through  the  complications  that  it 
produces  (utero-placental  haemorrhage),  may  obstruct  the  develop- 
ment of  the  ovum,  cause  the  death  of  the  foetus  and  prevent  preg- 
nancy from  arriving  at  normal  term.  Albuminuria  also  predisposes 
to  the  genital  haemorrhages.  But  the  result  most  to  be  feared  is 
eclampsia  which  threatens  the  pregnant  woman. 

The  treatment  will  vary  according  to  the  variety  of  the  albumin- 
uria. In  the  case  of  febrile,  cachectic  or  cardiopathy  albuminuria, 
the  presence  of  albumen  in  the  urine  is  only  of  secondary  importance 
and  the  treatment  should  be  directed  against  the  casual  affection. 
But  if  the  albuminuria  is  of  renal,  or  even  simply  of  gravid  origin, 
the  vice  of  secretion  produces  a  fear  of  eclampsia  and  the  efforts 


Extra-Genital  Diseases, 


275 


must  be  directed  to  the  endeavor  to  re-establish  elimination  or  to 
supplement  it  by  other  ways.  The  treatment  then  presents  a  dose 
analogy  with  that  of  eclampsia,  except  that  the  minor  therapeutic 
tripod  Here  holds  the  preponderating  importance.  The  minor  tripod 
consists,  as  in  eclampsia,  of  diuretics,  purgatives  and  diaphoretics. 
With  regard  to  the  major  tripod,  bleeding  will  only  be  employed  in 
exceptional  cases  and  when  eclampsia  is  imminent.  Under  anaes- 
thetics, Noeggerath  has  noted  the  beneficial  influence  of  hydrate  of 
chloral  on  albuminuria.  This  success  should  encourage  its  use. 
Dterine  depletion  consists  of  inducing  abortion  or  accouchement,  in 
very  exceptional  cases,  when,  in  spite  of  the  employment  of  the 
preceding  measures,  there  is  reason  to  fear  the  death  of  the  patient 
or  a  fatal  eclampsia. 


FlG.  312  — Esbach's  graduated  tubes,     a,  empty;  b,  filled, 
the  precipitate  being  deposited. 

G.  Regions. — Pregnancy  aggravates  the  majority  of  the  cutaneous 
diseases.  Under  the  influence  of  gestation  an  intense  generalized 
pruritus  may  develop,  sometimes  without  lesions,  sometimes  ac- 
companied by  vesicles  and  pustules.  Treatment :  alkaline  baths, 
lotions  of  cocaine  solution. 

The  result  of  traumatism  during  pregnancy  is  variable.  In 
general,  traumatism,  accidental  or  operative,  is  dangerous,  with  re- 
gard to  the  interruption  of  pregnancy,  in  proportion  as  it  approaches 
the  genital  sphere.  In  the  union  of  fractures  the  formation  of  the 
callus  is  often  retarded,  but  the  cicatrization  of  wounds  in  general 
is  not  interrupted  by  pregnancy. 


276 


Extra-Genital  Diseases. 


Fig.  31; 


-Mammary  bandage. 


An  abscess  of  the  breast  is  exceptional  during  pregnancy.  It  may 
be  produced,  however,  under  the  influence  of  traumatism,  of  excori- 
ation, or  of  eczema  of  the  nipple.  There  are  no  special  therapeutic 
considerations. 


FlG,  314. — Mammary  bandage  applied. 

Hypertrophy,  simple  exaggeration  of  the  normal  increase  due  to 
the  gravid  state,  may  be  observed.  This  hypertrophy  exists  some 
times  to  a  very  marked  degree.  After  accouchement  the  breasts 
return  to  nearly  normal  size.  Sometimes  this  regression  is  so  slow 
that  lactation  is  impossible.  The  various  means  of  treatment  that 
have  been  advised  are  ineffectual.  It  is  necessary  to  be  content 
with  a  simple  support  given  by  an  appropriate  bandage  (Figs.  313 
and  314). 


/-   eases  of  the  Bony  Pelvis.  -ii~ 


CHAPTER  XVIII. 


DISEASES   OF    THE   BONY   PELVIS. 

A.  Diseases  of  the  articulations. 

I.  Relaxation  of  the  symphyses.  —  The  three  articulations  which 
interrupt  the  pelvic  ring  are  subject,  during  pregnancy,  to  a  soften- 
ing of  their  tissues  that,  fortunately,  corrects  the  rigidity  of  the 
pelvis  in  view  of  accouchement.  This  physiological  state  may  become 
pathological  by  excess.  The  three  symphyses,  then,  are  subject  to  a 
veritable  relaxation,  more  easily  appreciable  at  the  pubes  than  at 
the  sacro-iliac  articulations.  This  articular  relaxation  is  manifested 
by  two  important  symptoms : 

a.  Functional  weakness. — The  woman  feels  an  increasing  difficulty 
in  walking.  She  waddles  in  walking.  It  seems  to  her  as  if  the 
thighs  could  no  longer  sustain  the  pelvis.  Walking  sometimes 
"becomes  impossible. 

6.  The  pain  relates  to  a  general  fatigue  and  to  suffering  at  the 
articular  interlines  of  the  pelvis.  Local  pressure  causes  a  most 
clear  exacerbation. 

By  examination  two  signs  are  found  which  confirm  the  diagnosis  : 

1.  The  abnormal  mobility  oj  the  bones.  —  The  woman  being  in  the 
upright  position,  the  finger  in  the  vagina  is  brought  into  relation 
with  the  symphysis  pubis.  Then,  when  the  patient  raises  the  limbs 
alternately,  an  independent  movement  of  the  two  articular  surfaces 
is  very  clearly  felt. 

2.  Articular  crepitation. — This  crepitation,  analogous  to  that  met 
in  an  old  arthritis,  only  rarely  exists  in  relaxation  of  the  symphyses. 
The  relaxation  generally  begins  at  a  variable  period  of  the  second 
half  of  pregnancy  and  is  marked  up  to  the  moment  of  accouche- 
ment. Cure  occurs  after  delivery  but  the  relaxation  sometimes 
persists  a  long  time.  The  consolidation  of  the  articulations  may 
even  remain  incomplete. 

Relaxation  of  the  symphyses  is  a  relatively  frequent  complication 
of  the  puerperal  state,  but  it  often  remains  unrecognized.  The 
painful  and  functional  disturbances  of  which  it  is  the  cause  being 
simply  and  wrongly  attributed  to  the  pregnancy  itself.  An  attentive 
exploration,  based  on  the  preceding  signs,  will  permit  an  easy 
diagnosis. 

The  only  efficacious  treatment  of  this  affection  consists  in  the 
application  of  a  bandage,  a  double  circle  around  the  pelvis,  giving 


278  Diseases  of  the  Bony  Pelvis. 

it  artificial  solidity.  The  best  apparatus  is  Martin's  belt,  com- 
posed of  a  circle  of  steel,  covered  by  soft  material,  which  passes 
above  the  trochanters  and  buckles  in  front,  This  belt  should  be 
made  to  order  and  exactly  molded  to  the  contour  of  the  body. 
Well  made  it  is  easily  supported  and  overcomes  the  greater  part  of 
the  inconveniences  of  relaxation  of  the  symphyses.  It  should  be 
worn  until  return  of  the  articulations  to  their  normal  state. 

II.  Inflammation  of  the  articulations. — Inflammation  of  the  pelvic 
symphyses  may  be  produced  in  three  principal  conditions : 

1.  In  consequence  of  relaxation  of  the  symphyses,  the  inflam- 
mation becoming  a  complication. 

•2.  In  consequence  of  rupture  of  an  articulation  any  obstetrical 
traumatism  (forceps,  version,  difficult  labor)  may  act  in  the  same 
way,  even  when  it  does  not  produce  a  complete  rupture  of  the  sym- 
physis attacked,  and  where  it  is  confined  to  a  simple  contusion. 

3.  Under  the  influence  of  the  puerperal  state ;  an  influence  ad- 
mitted when  no  other  cause  can  be  found  (perhaps  of  rheumatismal 
nature). 

This  arthritis,  attacking  one,  two,  or  all  three  symphyses  of  the 
pelvis,  is  manifested  by  a  fever  of  variable  intensity  and  locally  by 
pain  and  doughyness  of  the  diseased  articulation.  When  inflam- 
mation is  a  consequence  of  relaxation  or  of  rupture  the  symptoms 
of  these  different  affections  are  confused  and  make  diagnosis  more 
complicated. 

Termination  takes  place  by  cure,  in  a  few  days,  or  by  transfor- 
mation into  a  chronic  state,  or  by  suppuration. 

The  prognosis  naturally  varies  according  to  the  intensity  of  the 
disease. 

The  treatment  is  the  same  as  that  of  arthritis  in  general.  It  is 
useless  to  dwell  on  it  here.  Eepose  and  immobilization  of  the  pelvis 
constitute  its  basis. 

III.  Rupture  of  the  symphyses. — When  there  is  a  disproportion 
between  the  size  of  the  foetal  head  and  the  space  presented  by  the 
pelvic  passage,  if  the  accoucheur  (forceps,  manual  extraction)  or 
the  utero-abdominal  contraction  energetically  force  the  exit  of  the 
child,  there  may  result  a  fracture  of  the  fcetal  cranium,  or,  mo.e 
often,  a  rupture  of  one  of  the  pelvic  symphyses. 

The  symphysis  pubis  is  rarely  affected.  Usually  it  is  one  of  the 
sacro-iliac  symphyses  that  suffers.  This  is  easily  explained  by  the 
energetic  pressure  on  the  sacrum. 

At  the  moment  of  this  rupture  the  woman  feels  an  acute  pain,  a 
sensation  of  tearing ;  the  obstetrician  perceives  crepitation  and  the 
feeling  of  an  obstacle  suddenly  overcome,  analogous  to  that  given 


Diseases  of  the  Bony  Pelvis. 


279 


by  the  passage  of  the  bead  through  the  narrowed  promonto-pubic 
diameter  when  it  falls  into  the  excavation. 

Articular  rupture,  which  is  only  a  pronounced  sprain,  terminates 
in  inflammation.  The  consequences  of  the  accideni  are  those  of 
arthritis  with  a  veriable  progress  according  to  its  intensity.  The 
treatment  is  the  saint-  as  that  of  arthritis. 


Fig.  315. — Normal  pelvis. 


Fig.  316. — Antero-posterior  section  of  a  normal  pelvis. 

B.  Pelvic  deformities.— The  normal  conformation  of  the  bony 
pelvis  (Figs.  315,  31G)  has  already  been  considered,  it  is  useless  to 
review  it  here.  The  pelvis  is  deformed  whenever,  by  its  confor- 
mation or  by  its  direction,  it  deviates  from  the  normal  state.  The 
pelvic  deformities  can  be  divided  into  four  classes : 


280  Diseases  of  the  Bony  Pelvis. 

I.  Deformities  of  amplitude. 

1.  Pelvis  too  large. 

2.  Pelvis  too  small. 

II.  Deformities  of  length. 

1.  Pelvis  too  long,  too  deep. 

2.  Pelvis  too  short. 

III.  Deformities  of  direction. 

1.  Pelvis  in  anteversion. 

2.  Pelvis  in  retroveision. 

3.  Pelvis  in  lateroversion. 

IV.  Deformation  of  continuity . 
1.  The  cleft  pelvis. 

We  shall  successively  study  : 

A.  The  pathological  anatomy,  that  is,  the  conformation  of 

the  deformed  pelvis  and  at  the  same  time  the  etiology 
and  pathogeny. 

B.  The  symptomatology,  that  is,  the  symptoms  produced  during 

the  puerperal  state. 

C.  The  diagnosis. 

D.  The  prognosis. 

E.  The  management. 

A.  Pathological  anatomy;  JEtiology;  Pathogeny. — I.  Deformities  of 
amplitude. — We  shall  not  take  into  account  the  pelvis  that  is  too 
large,  for  its  importance  in  practice  is  mil.  The  narrowed  pelvis, 
on  the  contrary,  has  a  considerable  importance  on  account  of  its 
frequency  and  of  the  obstacle  to  accouchement.  Below  is  the 
classification  I  shall  follow  in  its  study : 

A.  Pelvis  with  simple  deformity. 

1.  Viciation  by  general  disease  (antero-posterior  contraction  by 
preference). 

(a).  Atrophy  (atrophic  pelvis).  J    2    JFlatlened 

Frequency,  20  p.  100.      j  ^  F]attened  justo.minor.      • 

C  1.  Justo-minor. 

(b).  Rachitis  (rachitic  pelvis).     J    2.  Flattened. 

Frequency,  60  per  100.      |    3.  Flattened  justo  minor. 

[  4.  Star-shaped,  figure-of-eight,  exostotic. 


(c).  Osteomalacia  (osteomalacic  pelvis).  \  gtar.sjiaped# 
Frequency,  1  per  100.  J  '     ' 


2.  Viciation  by  local  disease  (transverse  contraction  by  prefer- 
ence). 

(d).  Sacro-iliac  arthropathy  (sacro-iliac  J  I.  Simple  ovular  oblique  pelvis, 
pelvis).     Frequency,  1  per  100.    \  2.  Double  ovular  oblique  pelvis. 


Diseases  of  the  Bony  Pelvis. 


281 


(e).  Rachidian  deviation  (rachidian  pelvis),    f  '    .   . 

x   '        j?  .  v  r         '    {   2.  Scoliotic  pe  vis. 

Frequency,  10  per  ioo.  j  r.     ,      .    v  ,  . 

1         J         '  (.3.  Cyphotic  pelvis. 

(f).  Alteration  of  the  lower  limbs  f  j  With  simple  coxo-femoral  luxation, 
(crural  pelvis).  Frequency,  -j  '  (  With  double  coxo-femoral  luxation. 
5  per  ioo.  (  2.  Without  luxation. 

3.  Yiciation  by  invasion  (irregular  contraction). 

(g).  Spondylolisthesis  (vertebral  pelvis).     Frequency,  I  per  ioo. 
(h).  Fractures  (fractured  pelvis)      Frequency,  I  per  ioo. 
(i).  Tumors  (neoplastic  pelvis).     Frequency,  I  per  ioo. 

B.  Pelvis  with  complex  deformity. 

Frequency  nearly  equal  to  that  of  simple  deviations. 

A.  Pelvis  with  simple  deformity. 

(a).  Atrophy. — Outside  of  rachitis,  under  an  influence  still  unde- 
termined but  in  which  heredity  plays  an  important  role,  individuals 
are  seen  whose  body,  or  sometimes  only  a  part  (head,  thorax, 
pelvis)  is  subject  to  an  arrest  of  development.  This  atrophy,  when 
it  relates  to  the  female  pelvis,  produces  the  deviation  that  we  now 
study.  This  form  of  deformed  pelvis  may  present  three  types  of 
deviation. 


Fig.  317. — Atrophic  justo-minor  pelvis. 

1.  Justo-minor. — By  this  expression,  that  common  usage  has  con- 
firmed, and  that  is  opposed  to  a  justo- major  (generally  enlarged 
pelvis),  is  designated  a  pelvis  (Fig.  317)  in  which  all  the  diameters 
have  been  subjected  to  a  diminution,  or  rather  to  a  want  of  develop- 
ment.    It  is  a  pelvis  generally  narrowed,  with  perfect  form. 

'2.  Flattened  (flattened  atrophic  pelvis).  —  This  is  also  called 
Betschler's  pelvis.  Only  the  antero-posterior  diameters  are  con- 
tracted, the  transverse  or  oblique  remaining  normal  or  slightly 
enlarged.  Let  us  take  the  preceding  variety  and  push  the  sacrum 
forward  toward   the   pubes,  the   curvature   of  the  iliac  bones  is 


•2t>2 


Diseases  of  the  Bony  Pelvis. 


increased  by  this,  while  the  transverse  and  oblique  diameters  un- 
dergo a  certain  augmentation  (Fig.  318). 


Fig.  318. — Flattened  atrophic  pelvis. 

3.  Flattened  justo-minor. — Let  us  take  a  very  pronounced  justo- 
minor  pelvis  and,  as  before,  push  the  sacrum  forward.  The  result 
is  the  same,  that  is,  diminution  of  the  antero-posterior  diameter, 
increase  of  the  transverse  and  oblique.  However,  the  latter,  being 
primarily  very  narrow,  cannot  attain  the  normal  dimensions  and 
the  pelvis  remains  contracted  in  all  its  diameters,  but  with  pre- 
dominence  of  contraction  in  the  sacro-pubic  direction  (Fig.  319). 


Fig.  319. — Flattened  atrophic  justo-minor  pelvis. 

(b).  Rachitis. — This  disease,  occurring  during  the  first  two  or  three 
years  of  life,  is  characterized  by  a  disturbance  of  the  nutrition,  and 
especially  by  a  vicious  evolution  of  the  tissues  which  occurs  with 
ossification.  The  bones,  in  place  of  having,  from  a  normal  calci- 
fication, their  natural  solidity,  are  soft  and  of  little  resistance,  so 


Diseases  of  the  Bony  Pelvis. 


293 


that  they  curve  and  become  deformed.  Under  the  influence  of 
rachitis  pelvic  deviations  arise  which  have  a  great  analogy  with  the 
preceding  class  although  the  varieties  are  more  numerous. 

1.  Justo-minor  (rachitic  justo-minor  pelvis) — As  in  the  case  of  an 
atrophic  pelvis  the  lack  of  development  affects  all  the  pelvis.  There 
is  a  difference,  however,  as  the  contraction  is  especially  pronounced 
at  the  superior  strait  (Fig.  320).  There  is  at  this  level  an  anular 
contraction,  this  expression  being  opposed  to  that  ol  canalicidated, 
a  \  applied  to  stenoses  affecting  the  whole  of  the  bony  canal. 


Fig.  320. — Rachitic  justo-minor  pelvis. 

2.  Flattened  (flattened  rachitic  pelvis). — As  in  the  atrophic  pelvis, 
it  is  the  projection  of  the  sacrum,  and  especially  of  the  promontory 
toward  the  center  of  the  pelvis,  that  causes  the  antero-posterior 
flattening  (Fig.  321),  and  particularly  promonto-pubic,  at  the  same 
time  with  a  relative  increase,  sometimes  actual,  of  the  oblique  and 
transverse  diameters.  The  promonto-pubic  contraction  is  the  char- 
acteristic of  the  flattened  rachitic  pelvis.  Tins  variety  is  the  most 
frequent  of  all  the  pelvic  deformities. 


Flattened  rachitic  pelvis. 


3.  Flattened  justo-minor  (flattened  rachitic  justo-minor  pelvis). — 
This  is  a  combination  of  the  two  preceding  varieties,  which  causes 
a   contraction   of   ah    the    diameters   with    predominence   of   the 


284 


Diseases  of  the  Bony  Pelvis. 


shortening  of  the  antero-posterior  (Fig.  322).  As  in  all  the  varieties 
of  the  rachitic  pelvis,  the  stenosis  involves  especially  the  superior 
strait. 


Fig.  322. — Flattened  rachitic  justo-minor  pelvis. 

4.  Rachitic  pelvis  (in  star-shape,  in  figure-of-eight,  exostotic). — I 
have  grouped  in  the  same  paragraph  these  three  varieties  of  the 
rachitic  pelvis  as  they  are  seldom  seen. 


Fig.  323 — Star-shaped  rachitic  pelvis,  or  pseudo  osteomalacic. 

The  star-shaped  pelvis  (Fig.  323),  also  called  the  pseudo  osteo- 
malacic, presents  a  deformation  analogous  to  that  produced  by 
concentric  pressure  on  the  sacrum  and  the  femoral  heads.  The 
form  of  the  pelvis  is  almost  that  of  a  star  of  three  rays. 

The  pelvis  in  the  figure-of-eight  (Fig.  324)  is  constituted  by  a 
very  marked  approach  of  the  sacrum  and  the  pubes  toward  each 
other. 

The  exostotic  pelvis  is  remarkable  for  a  series  of  pointed  spines, 
at  the  sacro-iliac  symphysis,  at  the  ilio-pectineal  eminence,  at  the 
spine  of  the  pubes  (Fig.  325).     These  projections,  depeloped  under 


Diseases  of  the  Bony  Pelvis. 


-i*r, 


the  influence  of  rachitis,  are  capable  at  the  moment  of  accouchement 
of  perforating  the  soft  tissues. 

Whatever  the  variety  of  the  rachitic  pelvis,  the  sacrum  may 
present  independent  incurvations  that  arc  interesting  to  observe. 


Fig.  324. — Rachitic  figure-of-eight  pelvis. 

In  some  cases  the  curve  is  but  little  modified.  Sometimes  it  is 
exaggerated  (Fig.  326).  Then  a  false  promontory  is  constituted. 
In  other  cases  the  curve  may  be  straitened,  or  even  directed 
contrary  to  the  normal,  the  convexity  facing  the  center  of  the  pelvis. 
A.  false  promontory  is  also  formed  but  in  place  of  being  lumbar,  as 
before,  it  is  sacral  (Fig.  327)  and  found  at  the  union  of  the  first  and 
second  segment  of  the  sacrum. 


Fig.  325. — Exostotic  pelvis. 

(c.)  Osteomalacia  is  a  softening  of  the  bony  skeleton  occurring 
during  the  adult  period.  It  is  analogous  to  rachitism,  not  in  its 
lesions  but  in  its  results.  It  often  takes  its  origin  in  pregnancy. 
This  disease  produces  only  one  variety  of  pelvic  deformity,  the  star- 
shaped  pelvis  (Fig.  328). 


286 


Diseases  of  the  Bony  Pelvis. 


(d).  Sacro-iliac  arthropathy.—  Under  the  influence  of  an  affection 
of  the  right  or  left  sacro-iliac  articulation,  sometimes  of  both,  an 
affection  not  yet  well  determined,  but  which  appears  to  be  in  some 
cases  a  vice  of  conformation,  in  others  an  arthritis  of  tubercular 
nature  or  of  early  age,  there  is  formed  a  sacro-iliac  ankylosis,  with 
atrophy  and  resorption  of  the  contiguous  regions  of  the  ilium  and 
of  the  sacrum.  The  result  of  this  disease  on  the  configuration  of 
the  pelvis  will  vary  according  as  a  single  articulation  or  loth  are 
attacked : 


Fig.  326. — Rachitic  pelvis  with  false 
lumbar  promontory. 


Fig.  327. — Rachitic  pelvis  with  false 
sacral  promontory. 


1.  A  single  articulation  attached  (simple  ovular  oblique  pelvis  or 
Naegele's  pelvis).  Unilateral  sacro-iliac  pelvis.  —  The  sacrum  in- 
clines from  the  ankylosed  side.  The  diseased  iliac  bone  inclines 
toward  the  center  of  the  pelvis  pushing  the  opposed  ilium  in  (he 
contrary  direction,  so  that  the  symphysis  pubis  is  carried  toward  the 
healthy  side  (Fig.  329).  The  superior  strait  takes  the  form  of  an 
oval  with  the  long  axis  directed  obliquely.  The  transverse  and  the 
oblique  diameters  are  the  most  affected.  The  deviation  equally 
affects  the  superior  strait,  the  excavation  and  the  median  strait. 

2.  Both  articulations  attacked  (double  oblique  ovular  pelvis,  or 
Roberts'  pelvi3).  Bilateral  sacro-iliac  pelvis. — The  ankylosis,  occur- 
ring on  both  sides,  causes  a  transverse  approach  of  the  iliac  bones 
toward  each  other,  the  pubic  symphysis  remaining  median,  and 
p  hi-  symmetrical.  However,  the  analogy  with  the  preceding  form 
gives  it  the  name  of  double  oblique,  although,  properly  speaking,  it 
is  not  oblique.     The  contraction  is  especially  transverse  (Fig.  330). 


Diseases  of  the  Bony  Pelvis. 


■>Hl 


(e).  Rachidian  deviations. — We  shall  only  take  into  question  here 
the  simple  deformities  produced  by  rachidian  deviation  exclusively. 


Fig.  328. — Osteomalacic  pelvis. 


Fig.  329. — Simple  oblique  oval  pelvis  or  Nsegele  pelvis. 

1.  Lordosic  rachitic  pelvis— Lordosis  only  affects  the  pelvis  when 
it  exists  in  the  lumbar  region,  its  most  frequent  seat.  It  does  not 
act  on  the  conformation  of  the  pelvis,  but  simply  on  its  inclination 
forward,  which  is  marked  (Fig.  331) ;  there  is  pelvic  anteversion. 


288  Diseases  of  the  Bony  Pelvis. 

2.  Scoliotic  rachitic  pelvis. — The  action  of  scoliosis  on  the  pelvis 
may  be  multiplied  by  a  simple  lateral  inclination  or  by  an  actual 
deformity.  When  deformity  is  present  there  is  flattening  of  the 
lateral  half  of  the  pelvis  toward  which  the  deviated  lumbar  column 
inclines  (Fig.  332). 


Fig.  330. — Double  oblique  oval  pelvis  or  Roberts'  pelvis. 


FlG.  331. — Rachitic  lordosic  pelvis. 

3.  Cyphotic  rachitic  pelvis. — This  vertebral  deviation  is  capable  of 
causing,  either  an  inclination  of  the  jjelvis  backward,  elevating  the 


"Diseases  of  the  Bony  Pelvis. 


289 


symphysis  pubis,  approaching  the  plane  of  the  superior  strait  to  the 
horizontal,  or  a  special  and  characteristic  deformity  which  gives  the 

pelvis  the  form  of  a  funnel  (Fig.  333). 


Fig.  332. — Rachitic  scoliotic  pelvis. 


FlG.  333. — Rachitic  cyphotic  pelvis  (funnel-shaped  pelvis). 

(f).  Alterations  of  the  lower  limbs.— From  the  special  poiut  of  view 
that  we  occupy,  it  is  important  to  establish  two  distinct  categories, 
according  as  there  is,  or  is  not,  a  coxo-femoral  luxation  (simple  or 
double),  for  this  luxation  causes  a  special  deviation  of  the  pelvis. 
We  shall  then  study  successively  the  crural  pelvis  with  luxation  and 
the  crural  pelvis  without  luxation,  it  being  understood  that  the  term 
luxation  will  here  be  applied  exclusively  to  the  hip  joint. 

1.  Crural  pelvis  with  luxation  tilio-  femoral  pelvis  of  Gnenot). — A. 
Unilateral  luxation. — We  shall  note  here  cases  in  which  the  luxation 


290 


Diseases  of  the  Bony  Pelvis. 


is  backward,  that  is,  toward  the  external  iliac  fossa  or  the  great 
sacro-sciatic  notch;  luxation  forward  being  relatively  much  more 
rare  and  its  reaction  on  the  pelvis  still  undetermined.  The  ilium 
of  the  luxated  side  is  atrophied  (Fig.  334).  The  symphysis  pubis 
is  thrown  toward  the  diseased  side  by  the  atrophy  of  the  ilium. 


Crural  pelvis  with  unilateral  luxation. 


The  point  of  support  for  the  head  of  the  femur  being  displaced  up- 
ward the  ilium  undergoes  a  swinging  movement  which  draws  the 
ischium  away  from  the  center  of  the  pelvis.  The  result  of  this  is 
to  increase  the  dimensions  of  the  transverse  diameter  of  the  median 
and  of  the  inferior  strait,  while  those  of  the  same  diameter  of  the 
superior  strait  remain  normal  or  only  slightly  diminished.  Uni- 
lateral luxation,  especially,  produces,  then,  a  pelvic  asymmetry,  for 
the  contraction  which  may  result  at  the  superior  strait  is  but  little 
marked. 

B.  Bilateral  luxation  (Fig.  3-35). — The  alterations,  which  have 
been  described  for  one  side  of  the  pelvis,  exist  here  on  both  sides 
alike.  The  two  iliac  bones  have  been  subjected  to  a  certain  degree 
of  atrophy  and  to  a  swinging  movement  which  separates  the  two 
ischii.  The  result  is  a  notable  enlargement  of  the  inferior  and  of 
the  median  strait,  transversely  and  obliquely,  and  a  corresponding 
contraction  of  the  superior  strait.  The  displacement  of  the  two 
femoral  heads  backward  also  causes  a  pelvic  anteversion. 

2.  Crural  pelvis  without  luxation  (Fig.  336).  —  The  alterations  of 
the  lower  limbs,  which,  besides  coxo-femoral  luxations,  may  cause 
pelvic  deviations  are  numerous.  I  shall  only  cite  some  examples : 
Traumatic  affections — fracture,  resection,  amputation.  Spontane- 
ous affections — atrophy  of  a  limb  (congenital  or  acquired),  various 
lesions  of  the  articulations.     These  various  alterations  of  the  lower 


hi.-, ./-,  !  of  thi    Bony  Pelvis. 


291 


Limbs  only  act  on  the  pelvis  when  they  occur  before  the  fifteenth 

The  pelvic  deviations  which  result  from  different  alterations  are 
too  varied  and  too  little  known  to  allow  a  systematic  description. 
The  two  important  ideas  that  it  is  accessary  to  retain  are,  that 
ill  the  pelvis  becomes  asymmetrical;  rl)  one  side  is  subject  to 
flattening  or  to  an  atrophy  of  variable  degree. 


Fig.  335. — Crural  pelvis  with  bilateral  laceration. 


Fig.  336. — Crural  pelvis  without  luxatior. 

(g).  Spondylizeme  and  spondylolisthesis  (vertebral pelvis). — Spondy- 
lizeme  and  spondylolisthesis  are  connected  by  a  common  point,  the 
invasion  of  the  pelvis  by  the  lower  or  lumbar  portion  of  the  verte- 
bral column,  but  the  cause  and  the  nature  of  these  two  affections 
are  different. 


292 


Diseases  of  the  Bony  Pelvis. 


Spondylizenie  is  characterized  by  bending  forward  of  the  spine. 
One  or  more  of  the  diseased  vertebrae  become  carious,  weakened 
and  demolished,  and  the  contiguous  part  of  the  vertebral  column, 
being  no  longer  supported,  falls  toward  the  pelvis  (Fig.  337). 
Spondylolisthesis  is  produced  simply  by  a  gliding  of  the  last  lumbar 
vertebra  on  the  sacrum  (Fig.  338). 


Fig.  337. — Spondylizematous  pelvis. 


Fig.  338. — Spondylolisthesic  pelvis. 

(h).  Fractures  (fractured  pelvis) — A  crushing  of  the  pelvis  having 
produced  multiple  fractures  of  the  iliac  bones  and  of  the  sacrum, 


Diseases  of  the  Bony  Pelvis. 


these  become  the  cause  of  very  capricious  deformities.  The  dif- 
ferent varieties  cannot  be  made  to  conform  to  any  systematic 
description.  The  pelvis  is  more  or  less  invaded  by  a  vicioUB  reunion 
of  the  fragments  (Fig.  339). 


Fig.  339. — Fractured  pelvis. 

(i).  Tumors  {neoplastic pelvis) — The  two  varieties  of  tumors  which 
may  obstruct  the  pelvis  are  the  exostoses  (Fig.  340)  and  the  osteo- 
sarcomata  (341). 


Fig.  340 — Deformity  from  exostosis. 

B.  Complex  pelvic  deformities. — It  is  impossible  to  describe  here  all 
the  varied  types  created  by  the  different  combinations  of  deviation. 


•294 


Diseases  of  the  Bony  Pelvis. 


Knowing  the  simple  forms  of  deformity  it  is  easy  to  recognize  the 
composite  varieties.  There  are,  however,  some  which  demand  a  few 
lines  of  explanation.     These  are: 


Deformity  from  osteo-sarcoma. 


1.  The  scolio-rachitic  pelvis. — The  rachitis  simultaneously  attacks 
the  vertebral  column,  which  it  deviates,  and  the  pelvis,  which  it  de- 
forms. On  the  other  hand,  the  pelvis  may  he  subject  to  the  action 
of  both  rachitis  and  scoliosis.  The  deviation  is  analogous  to  that 
met  in  the  simple  scoliotic  pelvis  but  with  the  difference  that  the 
promontory  is  much  more  projecting  and  the  flattening  of  the  side 
attacked  is  more  marked. 


Fig.  342. — Cypho-scoliotic  pelv:.s. 

2.   The  cypho-raehitie  pelvis. — Rachitis  generally  causes  the  pro- 
jection of  the  promontory  forward,  cyphosis,  on  the  contrary,  throws 


ises  of  the  lion//  Pelvis. 


this  Bame  region  backward  in  Buch  a  way  that  these  two  inflaen 
-I  to  reciprocally  correct  the  deviation.     But  it'  the  eyph 
and  the  rachitis  are  very  pronounced  there  is,  al  the  same  time 
with  the  narrowing  of  the  inferior  pelvic  region,  a  projection  of  the 
promontory,  so  that  the  pelvis  is  contracted  antero-posteriorly  at  the 
superior  strait,  and  especially,  transversely  at  the  median  .-trait. 


Fig.  343. — Pelvis  too  long. 


3.  The  cypho- scoliotic  pelvis — Cyphosis  and  scoliosis  combining 
their  action  create  a  funnel-shaped  pelvis,  which  is  also  asym- 
metrical. (Fig.  342). 


Fig.  344. — Pelvis  too  short. 

II.  Deviations  of  length. — The  dimensions  of  the  height  of  the 
pelvis  are  sometimes  exaggerated  (pelvis  too  long)  (Fig.  348)  and 
sometimes  less  than  normal  (pelvis  too  short)  (Fig.  344).  These 
deviations  are  of  small  practical  importance.    The  second  facilitates 


296 


Diseases  of  the  Bony  Pelvis. 


accouchement  and  obstetrical  intervention ;  the  first,  on  the  contrary, 
renders  these  manoeuvres  difficult. 


Fig.  345. — Pelvic  anteversion. 

III.  Deviations  of  direction. — These  deviations  are,  in  the  majority 
of  cases,  the  result  of  deviations  of  the  vertebral  column. 

1.  Anteversion,  the  result  of  lumbar  lordosis,  is  a  lowering  of  the 
symphysis  pubis,  inclining  the  vulva  backward  and  approaching 
the  plane  of  the  superior  strait  to  the  vertical  (Fig.  345).  With  this 
inclination  engagement  of  the  fcetus  in  the  excavation  is  difficult. 


Fig.  346. — Pelvic  retroversion. 

2.  Retroversion  (Fig.  346),  the  result  of  cyphosis,  produces  an 
effect  contrary  to  that  of  anteversion.  The  vulva  is  directed  for- 
ward and  its  upper  part  can  be  seen  when  the  woman  is  erect 


I  lis,  asis  <>/  tin'    llmiii   Pclris. 


297 


and  the  thighs  together,  while  in  tin-  norma]  state  it  is  completely 
hidden  in  tin-  attitude. 

3.  Lutt ■mn ■rs'mii  i  Fig. :!  17 1,  or  lateral  inclination,  is  the  usual  con- 
sequence of  scoliosis  and  of  inequality  of  the  length  of  the  lower 
limbs.    It  influences  the  inclination  of  the  uterus  during  pregnancy. 


Fig.  347. — Pelvic  lateroversion. 

IV.  Deviations  of  continuity. — Only  one  type  of  this  deformity  is 
known;  that  is,  the  cleft  pelvis  of  Litzmann  (Fig.  348). 


Fig.  348. — Cleft  pelvis. 

B.  Symptomatology. — We  shall  study  here  the  influence  of 
the  pelvic  deformities  on  pregnancy  and  on  accouchement. 


298  Diseases  of  the  Bony  Pelvis. 

1.  Pregnancy. — Among  the  numerous  accusations  brought  against 
the  pelvic  deformities,  only  two  are  justified.  The  contraction  of 
the  superior  strait  impedes  the  engagement  of  the  foetal  part  during 
the  latter  part  of  pregnancy.  From  this  arises  the  practical  advice 
to  always  think  of  the  possibility  of  a  pelvic  deformity  when,  in  the 
vicinity  of  accouchement,  especially  in  a  primipara,  the  fcetal  head 
is  still  free  at  the  superior  strait.  This  default  of  engagement 
prevents  the  fixation  of  the  foetus  and  thus  facilitates  the  production 
of  vicious  presentations. 

2.  Accouchement. — The  default  of  engagement  and  the  late  en- 
gagement of  the  foetal  part,  favoring  the  premature  rupture  of  the 
bag  of  waters,  or  the  formation  of  a  voluminous  sac,  interrupts  the 
opening  of  the  cervix.  There  is  fear  of  transformation  of  the  vertex 
into  brow  or  face,  of  procidence  of  the  cord,  or  of  uterine  rupture. 
In  presentation  of  the  vertex  the  head  presents  certain  peculiarities 
of  descent  interesting  to  know. 

With  a  flattened  pelvis,  that  is  narrowed  between  the  promontory 
and  the  pubes,  the  head,  arrested  at  the  superior  strait,  is  placed 
transversely,  then  it  inclines  on  its  posterior  parietal  bone,  rarely 
on  its  anterior;  the  posterior  parietal  protuberance  passes  around 
the  promontory  by  a  twisting  movement,  which  usually  brings  the 
parietal  protuberance  to  the  side  opposed  to  where  it  is  found  pri- 
marily. Then  the  head  passes  the  contracted  superior  strait  by  a 
twisting  movement  of  the  posterior  parietal  protuberance  and  by 
swinging  the  biparietal  diameter. 

If  there  is  a  cyphotic  pelvis,  engagement,  occurs  with  greater 
facility,  disengagement,  on  the  contrary,  is  difficult  on  account  of 
the  contraction  of  the  median  and  of  the  inferior  strait.  The  head, 
in  particular,  is  often  arrested  at  the  level  of  the  sciatic  spines, 
where  the  projection  is  exaggerated  by  the  pelvic  deformity. 

It  is  impossible  to  study  the  descent  of  the  head  in  all  the  vari- 
eties of  pelvic  deviations.  Besides  the  details  of  these  different 
mechanisms  are  not  well  known. 

When  the  head  comes  last,  it  may  meet  in  the  pelvic  stenosis  the 
same  obstacle  to  its  passage  as  when  it  presents  first. 

In  the  viciated  pelvis  where  the  promontory  forms  a  very  marked 

projection  (rachitic  variety)  the  head,  arrested  at  the  superior  strait, 

sometimes  presents  in  the  region  which  is  in  contact  with  the  sacro- 

vertebral  angle  a  more  or  less  deep  depression,  that  in  exceptional 

becomes  a  fracture. 

C.  Diagnosis  {'pelvimetry). — To  arrive  at  the  knowledge  of  the 
different  pelvic  deformities  which  have  been  described  it  is  necessary 
to  measure  the  principal  diameters  of  the  pelvis,  or,  in  other  words, 
to  practice  pelvimetry.     Pelvimetry  may  be  instrumental  or  digital. 


Diseases  of  the  Bony  Pelvis. 


299 


1.  Instrumental  pelvimetry. — There  exist  a  greal  aumber  of  pel- 
vimeters, Bome  external,  a  variety  of  compass ;  others  mix<  d,  i  i  e 
branch  remaining  on  the  exterior  while  the  other  penetrates  into 
the  genital  organs,  and  finally,  the  internal  variety  (Fig.  849),  that 
i-  used  in  the  vagina  to  measure  the  distance  which  separatee  Ihe 
pubic  symphysis  from  the  promontory.  All  these  instruments  have 
fallen  into  a  just  oblivion,  dethroned  and  replaced  by  digital  pel- 
vimetry. 


£lj 


Fig.  349  — Pelvi-cephalometer  of  Budin. 

2.  Digital  pelvimetry  may  be  external  or  internal. 

It  is  external  when  it  relates  to  measurement  of  the  bisischiatic 
diameter.  The  woman  being  placed  on  the  side,  or  in  the  genu- 
pectoral  position,  the  two  thumbs  depressing  the  soft  tissues  seek 
the  internal  surface  of  the  ischium  on  each  side  in  contact  with 
which  they  are  maintained  while  an  assistant  measures  the  distance 
separating  the  two  exploring  fingers.  To  this  measure  there  is 
added  the  part  occupied  by  the  soft  tissues,  one  to  two  centimetres. 

In  internal  digital  pelvimetry,  by  the  introduction  of  the  index 
finger  (Fig.  3~0),  of  the  index  and  middle  finger  (Fig.  351),  or  of 
four  fingers  (Fig.  352),  one  can  measure  the  minimum  promonto- 
pubic  diameter  and  the  sacro-pubic  of  the  median  strait.  Only 
one  finger  should  be  used,  as  often  as  possible,  and  it  is  this  uni- 
digital  procedure  that  I  shall  describe  in  detail,  for  it  should  be 
familiar  to  every  physician. 

Minimum  promonto-pubic  diameter. — The  index  finger  introduced 
into  the  vagina  is  directed  toward  the  promontory.  When,  with  a 
perinseum  of  median  re>istance,  the  finger  cannot  arrive  at  the 
promontory,  the  pelvis  is  normal  (with  regard  to  the  promonto-pubic 


300 


Diseases  of  the  Bony  Pelvis. 


diameter,  the  one  most  often  shortened) ;  when,  on  the  contrary, 
the  finger  can  attain  this  point  there  is  deformity. 


Fig.  350. — Internal  unidigital  pelvimetry. 

Practical  conclusion :  Whenever  a  pregnant  woman  is  examined 
in  view  of  her  accouchement,  especially  if  a  primipara,  it  should 
never  be  forgotten  in  digital  examination  to  seek  the  promontory. 
If  it  cannot  be  reached,  the  chances  are  that  the  pelvis  is  normal, 
for  out  of  ten  cases  of  pelvic  deformity  it  can  be  admitted  that  nine 
attack  the  promonto-pubic  diameter. 


Fig.  351. — Internal  bidigital  pelvimetry. 

When  the  promontory  is  attained,  the  radial  border  of  the  hand 
is  applied  against  the  inferior  part  of  the  symphysis  pubis  and  with 
the  index  finger  of  the  other  hand  the  limit  of  the  symphysis  is 
marked,  taking  care  to  determine  this  point  as  exactly  as  possible. 
An  assistant  measures  the  distance  which  separates  the  extremity 
of  the  index  finger  from  the  point  marked  and  the  length  of  the 
promonto-subpubic  diameter  is  thus  known. 


/'        es  of  the  Bony  Pelvis.  801 

Now  this  diameter  (in  the  normal  state  twelve  centimetei 
gei iv rally  one  centimetre  greater  than  the  promonto-suprapubic 
and  one  and  one-hali  centimetres  greater  than  the  minimum  pro- 
monto-pubic  It  is  necessary  then  to  subtract  one  and  one-half 
centimeters  from  the  length  found  to  obtain  the  minimum  pro- 
monto-pnbic  diameter. 


Fig.  352. — Internal  quadridigital  pelvimetry. 

"When  the  promontory  is  relatively  high,  or  when  it  is  desired  to 
measure  a  false  lumbar  promontory,  two  centimetres  are  subtracted. 
In  the  contrary  case,  and  with  a  false  sacral  promontory,  only  one 
centimetre,  for  the  difference  between  the  promonto- subpubic  and 
the  minimum  pubic  diameters  is  exaggerated  as  much  more  as  the 
promontory  is  elevated  and  diminishes  as  it  is  lowered  (Figs.  353 
and  354). 

Subsacro-subpubic  diameter.  —  We  proceed  as  above,  seeking,  by 
means  of  movements  given  to  the  coccyx,  the  sacro-coccygeal  articu- 
lation. The  distance  obtained  to  the  edge  of  the  pubes  is  measured 
on  the  exploring  finger;  this  is,  without  reduction,  the  subsacro- 
subpubic  diameter. 

Knowing  these  elements  of  pelvimetry  we  can  study  the  diagnosis 
of  the  pelvic  deformities.  Here  there  will  only  be  in  question  the 
simple  contractions,  as  I  shall  eliminate  all  the  other  viciations, 
their  importance  being  secondary. 

It  will  be  easy  to  suspect  and  to  recognize  the  atrophic  pelvis  in  a 
dwarf,  the  conformation  of  the  woman  will  put  us  on  the  track  of 
the  diagnosis.  But  if  the  conformation  be  normal,  the  vagino-pelvic 
exploration  alone  will  lead  to  the  diagnosis.  Digital  pelvimetry  will 
give  the  dimensions  of  the  antero-posterior  diameters  and  especially 
the  minimum  promonto-pubic.  For  the  transverse  dimensions,  it 
is  necessary  to  be  content  with  an  approximate  valuation. 


302 


Diseases  of  the  Bony  Pelvis. 


FlG.  353. Promonto-pubic  diameters  (Budin).     S,  sacrum;    Pr,  promontory ;    Sp, 

promonto-subpubic  diameter,  twelve  centimetres ;   Pu,  promonto-suprapubic  diameter, 
eleven  centimetres;  m,  minimum  promonto-pubic  diameter,  ten  and  a-half  centimetres. 


FIG.  354. Variations  of  promonto-pubic  diameters,  according  to  the  relative 

height  of  the  symphysis  pubis  and  of  the  promontory  (Budin). 

The  rachitic  pelvis  will  often  be  devined  from  the  general  aspect 
of  the  woman,  small  figure,  large  head,  face  sometimes  asym- 
metrical, teeth  bad,  thorax  prominent,  deviation  of  the  vertebral 
column,  alteration  in  the  curvature  of  the  lower  limbs,  finally,  walk- 
ing will  have  been  late,  at  two  or  three  years  of  age  instead  of  a  year. 


Diseases  of  the  Bony  Pedis.  :;o:i 

Direct  examination  will  permit  completion  of  the  diagnosis,  and  will 
afford  recognition  of  the  variety  and  degree  of  the  rachitic  deviation. 
The  three  types  of  the  atrophic  pelvis  will  only  be  distinguished 
from  the  three  corresponding  varieties  of  the  rachitic  pelvis  by  the 

aetiology  (rachitis  exists  in  the  second  case  while  there  is  no  trace  of 
it  in  the  first).  In  general  the  degree  of  viciation  is  relatively  slight 
in  the  atrophic  pelvis  while  it  may  be  very  pronounced  in  the 
rachitic. 

The  osteomalacic  pelvis,  besides  the  history  which  may  throw 
some  light  on  the  causal  disease,  is  recognized  by  its  special  form. 
The  projection  constituted  by  the  symphysis  pubis  and  the  osseous 
defile  which  exists  behind  it  are  characteristic  of  the  osteomalacic 
pelvis. 

The  sacro-iliac  pelvis  is  recognized  by  the  marked  flattening  of 
one  or  of  both  sides  of  the  pelvis,  with  absence  of  cause  with  regard 
to  the  vertebral  column  and  the  lower  limbs. 

The  rachitic,  lordosic,  scoliotic  or  cyphotic  pelvis  will  be  noted  by 
the  spinal  deviation  which  thus  serves  as  a  guide.  The  diagnosis 
will  be  controlled  and  verified  by  direct  exploration. 

The  crural  pelvis  will  be  sought  in  cases  of  alteration  of  the  lower 
limbs.  Its  diagnosis  is  of  secondary  importance,  for  it  is  rare  that 
the  deviation  is  marked. 

I  only  mention  the  diagnosis  of  the  vertebral,  fractured,  and  neo- 
plastic pelvis,  as  these  varieties  can  be  considered  as  exceptions. 

D.  Prognosis. — The  prognosis  for  the  mother  and  for  the  child 
will  vary  essentially  with  the  degree  of  the  pelvic  deformity. 

A  contraction  of  a  few  millimetres  is  without  importance. 

A  more  marked  contraction,  two,  three,  to  four  centimetres,  for 
example,  becomes  much  more  serious,  for  it  may  necessitate  more 
or  less  dangerous  interventions  (induced  accouchement,  forceps, 
version,  embryotomy) . 

A  very  pronounced  contraction  renders  the  prognosis  exceedingly 
grave,  for  there  is  often  no  other  means  of  delivering  the  woman 
except  Caesarian  section. 

In  the  same  woman  the  prognosis  of  the  deformity  becomes  more 
serious  as  the  number  of  pregnancies  become  greater.  Thus  it 
often  happens  that  a  pelvic  deformity  does  not  cause  any  difficulty 
in  the  first  and  second  accouchement  but  becomes  a  serious  obstacle 
in  the  third  and  fourth.  This  increasing  gravity  is  probably  due  to 
the  increasing  volume  of  the  foetus  at  each  new  gestation. 

E.  Management. — In  obstetrical  language  there  are  currently 
employed  the  expressions,  pelvis  of  eight  centimetres,  pelvis  of  >ix 
centimetres,  etc.  By  this  we  mean  a  pelvis  the  shortest  diameter  of 
which  measures  eight  centimetres,  six  centimetres,  etc.     A  normal 


304  Diseases  of  the  Bony  Pelvis. 

pelvis  is  consequently  a  pelvis  of  ten  centimetres.  The  degree  of 
violation  is  quite  variable,  but  a  pelvis  of  less  than  five  centimetres 
is  exceptional.  The  promonto-pubic  diameter,  being  most  often 
subject  to  deviation,  is  that  which  usually  gives  the  figure  to  the 
pelvis. 

The  foetus  which  must  pass  through  the  contracted  pelvis  should 
have,  during  accouchement,  the  head  so  placed  that  the  antero- 
posterior cephalic  diameters  correspond  to  the  largest  space  of  the 
pelvis,  the  most  narrow  pelvic  diameter  being  reserved  for  the  trans- 
verse, the  biparietal. 

Now  the  biparietal  measures  at  the  end  of  the  sixth  month,  six 
centimetres;  seventh  month,  seven  centimetres;  eighth  month, 
eight  centimetres ;  ninth  month,  nine  centimetres. 

A  pelvis  of  nine  would  permit  accouchement,  then,  at  term,  a 
pelvis  of  eight  at  eight  months ;  of  seven  at  seven  months ;  six  at  six 
months.  Six  complete  months  being  the  minimum  term  for  the 
viability  of  the  child,  it  will  be  seen  that  below  a  pelvis  of  six  centi- 
metres it  will  be  impossible  to  deliver  a  woman  of  a  viable  child  by 
the  natural  passages. 

With  these  preliminaries  let  us  study  the  conduct  to  be  followed. 
We  have  five  points  to  examine  according  as  we  are  asked  advice 
for  a 

a.  Young  girl  to  marry. 

b.  Married  woman  not  pregnant. 

c.  Pregnant  woman. 

d.  Woman  in  labor. 

e.  Special  cases. 

a.  Young  girl  to  marry. — If  there  exists  a  pelvic  deformity  local 
examination  will  recognize : 

Pelvis  below  six  centimetres,  no  marriage,  for  except  by  Caeserian 
section  it  will  be  impossible  for  the  woman  to  have  a  viable  child. 

Pelvis  of  six  to  nine  centimetres,  marriage  is  possible,  but  the 
necessity  of  inducing  early  accouchement  will  be  foreseen. 

Pelvis  above  nine  centimetres,  marriage  is  possible.  Accouche- 
ment may  take  place  at  term  but  it  should  be  explained  that  it  may 
be  difficult. 

h.  Married  woman  not  pregnant. — Pelvis  below  six  centimetres,  no 
pregnancy. 

Pelvis  of  six  to  nine  centimetres,  pregnancy  possible,  but  neces- 
sity of  inducing  accouchement  before  term. 

Pelvis  above  nine  centimetres,  pregnancy  can  go  to  term,  but  on 
account  of  the  possible  difficulties  accouchement  demands  special 
care. 


"Diseases  of  the  Bony  Pelvis.  305 

c.  Pregnant  woman. — Three  circumstances  may  present: 

1.  Woman  and  child  normally  healthy: 

Pelvis  below  six  centimetres,  to  induce  abortion,  unless  the  woman 
demands  Cfflsarian  section  at  term. 

Pelvis  from  six  to  nine  centimetres,  to  induce  accouchement  at  a 
date  indicated  by  the  degree  of  contraction. 

Pelvis  of  six  centimetres  at  six  months  (beginning  of  the  seventh 
month);  pelvis  of  seven  centimetres  at  seven  months;  pelvis  ol 
eight  centimetres  at  eight  months. 

2.  Woman  healthy  and  child  dead. — No  intervention  is  necessary. 
Await  the  spontaneous  appearance  of  labor. 

3.  Woman  unhealthy,  child  healthy. — If  the  disease  affecting  the 
woman  is  without  gravity  the  management  remains  the  same  as  if 
she  were  healthy.  But  if  the  disease  is  grave,  fatal"  (cancer,  ad- 
vanced tuberculosis) ;  the  child's  life  is  to  be  regarded  above  all.  the 
woman  being  condemned.  In  such  cases  the  physician  will  be 
authorized  to  allow  pregnancy  to  go  to  term  and  to  perform 
Ca  sarian  section. 

<L   Woman  in  labor. — Three  circumstances  may  be  present : 

1.  Accouchement  may  be  spontaneous; 

2.  Or,  it  will  be  necessary  to  resort  to  forceps  or  to  version, 
interventions  of  the  first  degree ; 

3.  Or,  as  a  last  resource,  to  perform  embryotomy  or  hysterotomy, 
interventions  of  the  second  degree. 

Parallel  between  forcejis  and  version. — The  parallel  between  these 
two  operations,  employed  in  the  case  of  pelvic  deformity,  has  given 
rise  to  long  discussions.  In  intervening  we  especially  have  in  view 
the  passage  of  the  foetal  head.  Now,  on  the  manikin,  with  the 
same  degree  of  pelvic  stenosis,  the  extraction  of  the  head  last 
(version)  is  incontestably  more  easy  than  first,  with  the  forceps. 

It  is  the  same  in  a  living  woman  with  a  dead  child,  on  account  of 
the  mobility  allowed  the  head  by  the  hands  and  of  the  possibility 
of  giving  it  different  movements  that  the  forceps  do  not  permit. 

But  with  a  living  child  we  meet  a  new  element,  the  life  of  the 
child. 

By  the  aid  of  the  forceps  (head  first)  traction  can  be  made  during 
a  half-hour,  and  even  more,  and  still  a  living  child  may  be  delivered. 
With  version  if  the  head,  being  last,  is  not  extracted  in  less  than 
five  minutes  the  death  of  the  child  is  assured. 

Version  having  the  greatest  difficulty  in  the  extraction  of  the  head 
and  forceps  exposing  less  to  the  death  of  the  fcetus,  it  is  very  diffi- 
cult to  decide  categorically  between  these  two  modes  of  intervention. 

Version  seems  preferable,  however,  in  presentations  other  than 
those  of  the  vertex  (simple  extraction  in  presentation  of  the  breech). 


306  Diseases  of  the  Bony  Pelvis. 

The  forceps,  on  the  contrary,  will  be  better  in  the  majority  of  pre- 
sentations of  the  vertex,  unless  the  head  is  very  high,  or  except 
when  there  is  procidence  of  a  limb  or  of  the  cord  or  any  analogous 
condition  rendering  the  application  of  the  instrument  difficult. 

Parallel  between  hysterotomy  and  embryotomy.  —  I  shall  only  pre- 
sent a  resume  of  this  subject. 

A.  Mother  healthy,  child  dead  or  condemned. 

When  manual  extraction  or  by  the  forceps  is  impossible, 
recourse  to  embryotomy.  Hysterotomy  will  only  be  in- 
dicated when  embryotomy  is  not  practical  on  account  of 
the  degree  of  pelvic  contraction. 

B.  Mother  dying  or  condemned,  child  healthy. 

Hysterotomy  will  here  be  preferable  to  embryotomy. 

C.  Both  mother  and  child  healthy. 

1.  Pelvis  about  nine  centimetres. 

Territory  of  manual  extraction  or  of  the  forceps. 
Possible  invasion  of  embryotomy. 

2.  Pelvis  seven  to  nine  centimetres. 

Territory  of  embryotomy. 

Possible  invasion  of  manual  extraction  or  of  the  forceps,, 
which  should  always  be  previously  attempted. 

3.  Pelvis  of  five  to  seven  centimetres. 

Territory  common  to  hysterotomy  and  to  embryotomy. 
The  choice  should  be  in  part  left  to  the  woman, 
leaving  her  free  to  expose  herself  or  not  to  save  her 
child. 

4.  Pelvis  below  five  centimetres. 

Territory  of  embryotomy. 

e.  Special  cases. — Certain  pelvic  deformities,  for  example,  osteo- 
malacia may  modify  the  line  of  conduct  previously  traced.  In 
osteomalacia  the  pelvic  bones  may  present,  when  the  disease  is 
recent,  a  certain  suppleness  which  allows  a  relative  facility  of  ac- 
couchement. 

In  a  general  manner,  the  narrowing  of  the  median  strait  is  less 
grave  than  that  of  the  superior,  for  the  foetal  head  being  less  distant 
intervention  becomes  easier. 

In  the  same  way  a  multiple  pregnancy,  monstrosities,  etc.,  create 
special  conditions,  into  the  detail  of  which  it  is  impossible  to  enter. 


Diseases  oj  the  Genital  System,  307 


CHAPTER  XIX. 


DISEASES   OF   THE  GENITAL    SYSTEM   AND  ITS 
DEPENDENCIES.— GENITAL   DYSTOCIA. 

1.  Narrowness  and  rigidity  of the  vulva  are  especially  observed  in 
women  first  becoming  pregnant  late  in  life,  or  in  consequence  of 
morbid  processes  having  caused  local  modifications  of  the  external 
genital  organs.  Treatment:  Prolonged  bath  during  labor;  forceps 
or  manual  extraction;  recourse  to  vulvar  incisions  only  when  abso- 
solutely  necessary. 

'2.  Hymen. — Vaginismus.  —  The  persistence  of  the  hymen  after 
coitus,  or  rather  the  insistence  of  the  ring  surrounding  it,  some- 
times obstructs  the  exit  of  the  foetus.  The  contractions  of  the 
constrictor  muscle  of  the  vulva  or  of  the  levator  ani  may  also  be  a 
cause  of  dystocia.  Treatment :  Chloroform  in  a  dose  sufficient  to 
cause  muscular  relaxation;  forceps  or  manual  extraction ;  incisions 
rarely  necessary. 

3.  Vices  of  vulvar  conformation. — Cicatrices. — The  anomalies  of  the 
vulva  and  cicatrices  in  consequence  of  traumatism,  gangrene,  soft 
chancres,  etc.,  may  impede  ampliation  of  this  portion  of  the  genital 
organs  and  obstruct  expulsion.  There  sometimes  exists  an  anomaly 
in  the  situation  of  the  vulva,  too  far  forward  or  backward ;  the  first 
obstructs  accouchement,  the  second  facilitates  it.  In  difficult  cases 
the  treatment  is  the  same  as  for  vulvar  narrowness. 

4.  Tumors. — Vegetations,  hypertrophic  mucous  plaques,  cancer, 
cedema  causing  a  tumefaction  that  is  sometimes  enormous,  consti- 
tutes dystocic  causes  of  variable  importance.  Treatment :  Manual 
or  forceps  extraction,  as  slow  as  possible,  to  avoid  great  vulvar 
lacerations. 

5.  Vices  of  conformation  of  the  vagina. — Cicatrices.  —  Besides  du- 
plicity there  may  exist  in  the  vagina  transverse  bands,  sometimes 
a  veritable  diaphragm  of  congenital  origin,  or  cicatrices  of  variable 
resistance,  consecutive  to  the  traumatisms  of  previous  accouche- 
ment. Treatment :  simple  expectation  in  slight  cases.  Prolonged 
hot  injections,  application  in  the  vagina  of  a  rubber  dilator,  vaginal 
massage,  incisions,  manual  or  forceps  extraction. 

6.  Vaginal  prolapsus,  unless  accompanied  by  a  marked  degree  of 
uterine  descent,  is  of  small  importance ;  however,  it  exposes  to 
gangrene  of  the  vagina]  fold  projecting  through  the  vulva  when  the 
head  remains  too  long  at  the  perineum.  Treatment :  sustain  the 
vaginal  fold  with  the  fingers.     Terminate  the  accouchement  at  need 


308  Diseases  of  the  Genital  System. 

by  the  forceps  or  by  manual  extraction,  having  the  vagina  sustained 
by  an  assistant  in  the  meantime. 

7.  Tumors.  —  Thrombus. — Cysts  of  the  vagina  are  rarely  large 
enough  to  cause  dystocia.  The  most  important  tumor  of  the  vagina, 
for  dystocia,  is  thrombus.  This  interstitial  haemorrhage  results  from 
the  rupture  of  a  normal  vein,  but  most  often  is  produced  by  the 
rupture  of  a  varicose  vein.  It  is  exceptional  before  accouchement, 
rare  during  labor,  and  most  frequent  after  delivery.  Treatment : 
to  abstain  as  much  as  possible ;  during  pregnancy  horizontal  repose ; 
during  labor,  to  terminate  the  accouchement  as  soon  as  possible,  and 
only  to  incise  the  tumor  when  it  opposes  an  absolute  obstacle  to  the 
passage  of  the  foetus. 

8.  Resistance  and  oedema  of  the  perirusum. — Recognize  the  same 
causes  as  for  these  conditions  of  the  vulva  and  require  the  same 
treatment.     Perinaeal  lacerations  have  already  been  considered. 

9.  Obliteration  of  the  cervix. — Agglutination  of  the  lips  of  the  ex- 
ternal orifice  is  without  importance  and  gives  way,  without  difficulty, 
to  the  action  of  uterine  contraction.  Fibrous  obliteration,  affecting 
the  internal  or  the  external  os  in  consequence  of  ulcerations  or 
caustic  treatment,  prevents  the  opening  of  the  cervix.  This  ob- 
literation may  be  confused  with  a  simple  deviation  of  the  cervix  and 
it  demands  careful  exploration,  under  anaesthesia,  if  necessary.  If 
the  obliteration  of  the  cervix  is  real  a  cervical  incision  will  be  made 
in  the  supposed  site  of  the  external  os,  controlling  its  extent  by  the 
use  of  the  speculum  and  vision.  This  opening  is  slowly  enlarged, 
by  multiple  incisions,  taking  care  not  to  wound  the  foetus. 

10.  Rigidity  of  the  cervix  has  been  divided  into  pathological,  spas- 
modic, and  anatomical. 

Pathological,  that  is  to  say,  caused  by  the  existence  of  a  cervical 
affection,  parenchymatous  metritis,  cicatrices,  fibromata,  cancer. 

Spasmodic,  due  to  muscular  contraction  of  the  cervix,  and  es- 
pecially of  the  inferior  segment  of  the  uterus,  for  the  latter  is  richer 
in  muscular  fibres  than  the  cervix.  The  cervix  and  the  inferior 
segment  are  painful,  sensitive  to  pressure,  hot,  thin  and  tense  if 
effacement  is  completed.  The  uterine  contractions  are  irregular. 
Often  there  is  fever.  The  dilatation  of  the  cervix  remains  station- 
ary or  only  advances  very  little,  in  spite  of  the  acute  sufferings  of 
the  woman.  This  spasmodic  rigidity  is  due  to  too  repeated  ex- 
plorations, to  manceuvers  intended  to  dilate  the  cervix,  to  any  cause 
capable  of  irritating  the  cervix,  but  especially  to  the  administration 
of  ergot  during  labor.  Treatment :  chloral  and  chloroform,  as  for 
obstetrical  anaesthesia.  If  the  spasmodic  rigidity  does  not  yield  to 
these  measures  it  is  on  account  of  association  with  a  pathological 
state. 


Diseases  of  the  Genital  System.  809 

Anatomical. — This  rigidity  16  due  to  a  Bpecial  Btate  of  the  cervix 
(and  not  of  the  inferior  segment,  as  in  the  spasmodic)  which  im- 
pedes the  opening  and  the  dilatation  of  the  uterine  orifice.  This 
rigidity  may  be  relative,  that  is,  the  uterine  contractions  are  noi 
sufficient  to  vanquish  the  normal  resistance  of  the  cervix;  this  i.^  a 
false  rigidity  that  must  he  eliminated  from  this  class,  as  it  only  in- 
cludes real  or  absolute  rigidity  in  which  the  uterine  contraction- 
are  normal. 

Contrary  to  the  spasmodic  variety,  the  effaced  cervix  is  hard, 
thick,  resisting,  not  painful  and  gives  the  sensation  of  leather 
soaked  in  grease.  The  uterine  contractions  are  very  painful,  with 
lumbar  predominance  of  the  pain.  The  dilatation  is  effected  with 
an  extreme  slowness  and  may  last  several  days. 

The  cause  of  this  rigidity  is  the  incomplete  softening  of  the 
cervix  under  the  influence  of  pregnancy.  Labor  occurs  before  the 
puerperal  state  has  sufficiently  prepared  the  cervical  portion  for 
the  distention  to  which  it  is  subjected,  thus  premature  accouche- 
ment is  a  frequent  cause. 

Treatment. — Procedures  of  the  first  degree. — Prolonged  baths  with 
vaginal  injections  in  the  bath.  Irrigations  of  hot  water.  Borated 
glycerine  or  vaseline  applied  to  the  cervix  in  large  quantities. 
Chloral  applications  to  diminish  the  pain.  Dilating  rubber-bag  in- 
troduced into  the  cervix. 

Procedures  of  the  second  degree  (only  exceptionally  employed  and  in 
case  of 'absolute  necessity). — Dilatation  by  a  metallic  instrument  (Fig. 
355).  Multiple  incisions  (dangerous).  Manual  extraction  or  ex- 
traction with  the  forceps  before  complete  dilatation,  taking  care  to 
make  very  gentle  and  prolonged  tractions  during  a  half  hour,  three 
quarters  of  an  hour,  an  hour  or  even  more,  during  which  the  woman 
is  kept  under  the  influence  of  anaesthesia. 

11.  Deviations  of  the  cervix. — The  cervix  or  the  external  orifice 
after  effacement  may  be  deviated  forward,  backward  or  laterally, 
in  the  direction  of  the  different  vaginal  culs-de-sac.  The  cause  is 
either  in  the  inclination  of  the  body  of  the  uterus,  the  cervix  being 
carried  in  the  inverse  direction,  or  in  the  unequal  development  of 
the  inferior  segment  of  the  organ.  Deviation  backward  and  to  the 
left  is  normal.  In  the  pathological  state  it  is  the  exaggeration  of 
this  deviation  that  is  most  often  observed.  The  treatment  is  nul 
during  pregnancy.  At  the  moment  of  labor  the  deviation  is  cor- 
rected by  the  position  of  the  woman  or  by  drawing  on  the  external 
orifice  with  the  hooked  linger  to  replace  it  in  the  normal  position. 

12.  Tumors  of  the  cervix  uteri. — (Edema  occurring  during  ac- 
couchement is  sometimes  localized  in  a  segment  of  the  cervix  and 
sometimes  generalized.  It  requires  no  especial  treatment.  Simple 
hypertrophy  is   exceptionally  a  cause  of   dystocia.     Vegetations, 


310 


Diseases  of  the  Genital  System. 


abscess  and  thrombus  are  pathological  varieties.  The  fibromata. 
will  be  studied  with  those  of  the  body.  Cancer,  on  account  of  its 
importance,  merits  a  description  as  to  management. 

Management. — Before  conception,  advise  avoidance  of  pregnancy 
in  an  absolute  manner. 

During  pregnancy. — Simple  expectation  with  treatment  of  the 
pains  and  haemorrhages  by  the  usual  measures,  unless  the  mother 
is  menaced  by  death,  in  which  case  we  have  recourse,  if  the  child  is 
living  and  viable,  to  induced  labor,  or  to  Caesarian  section  before  or 
after  death.  Amputation  of  the  cancerous  cervix  and  ablation  of 
the  whole  uterus  have  been  proposed  and  practiced  but  these  op- 
erations are  not  to  be  advised  any  more  than  curetting  and  the 
actual  cautery  ( ?)  as  palliatives. 


FlG.  355. — Metallic  dilator  with  six  blades. 

Thiring  lahor. — Incomplete  dilatation. — a.  While  dilatation  is  pro- 
gressing, whatever  its  slowness,  expectation  is  the  best  conduct  un- 
less a  pressing  danger  menaces  the  mother  or  the  child.  If  the 
dilatation  is  stationary,  if  the  mother  or  the  child  is  in  peril,  it  is 


Diseases  of  the  Genital  System. 


311 


necessary  to  terminate  accouchement  artificially.  With  a  dead 
child,  or  when  its  chances  of  life  are  very  small,  embryotomy  should 
be  resorted  to  as  much  as  possible.  With  a  living  child,  manual 
extraction  or  the  forceps  will  be  attempted  if  the  dilatation  is  suf- 
ficient. If  the  dilation  is  insufficient  to  attempt  this  intervention, 
( la  sarian  section  should  he  performed  without  hesitation.  In  some 
cases  the  extent  of  the  cancerous  invasion  allows  us  to  foresee  the 
impossibility  of  dilatation  of  the  cervix  and  the  necessity  for  a 
( Ifflsarian  operation. 

(/>).  If  dilatation  is  complete  or  a  most  incomplete,  extraction  will 
he  made  as  soon  as  possible  by  the  usual  methods.  If  a  serious 
hemorrhage  follows  after  delivery  utero-vaginal  tamponnement  is 
the  preferable  treatment. 


Fig.  356. 

Heart-shaped 
uterus. 


Fig.  357. 

Divided  uterus. 


Double  uterus. 


Fig.  359. 

Double  uterus  and 
vagina  divided. 


Fig.  360. 

Double  uterus 
and  vagina. 


13.  Vices  of  conformation  of  the  uterus. — These  are  constituted  by 
incomplete  fusion  of  Muller's  canals.  They  are  of  various  degrees 
(Figs.  356-360). 

These  anomalies  of  conformation  may  be  the  cause  of  vicious 
presentations.  They  expose  to  uterine  rupture  and  render  inter- 
ventions difficult.  Then*  management  does  not  present  any  con- 
sideration of  special  importance. 

14.  Anomalies  of  uterine  contractions. — There  may  be  exaggeration, 
weakness,  or  perversion  of  uterine  contractions. 

Exaggeration  in  intensity,  which  exposes  to  rupture  of  the  uterus, 
or  to  laceration  of  the  perinaeum,  will  be  quieted  by  the  use  of 
chloral  and  of  chloroform. 

Weakening  of  the  contractions,  leading  to  uterine  inertia  during 
labor  or  delivery,  is  a  state  frequently  observed,  but  which  is 
usually  intermittent  and  passing.  It  is  most  often  produced  by 
exaggerated  distention  of  the  uterus,  by  the  death  of  the  foetus,  by 
the  length  of  labor  or  by  certain  acute  moral  impressions  in 
nervous  women. 

Uterine  inertia,  while  grave  after  delivery,  has  usually  no  other 
inconvenience  during  labor  than  that  of  prolonging  accouchement. 
During  labor,  to  wait  will  generally  be  the  better  plan.     If  not, 


312 


Diseases  of  the  Genital  System. 


there  are  several  measures  which  often  succeed.  They  are :  To 
modify  the  position  of  the  woman,  to  make  her  rise  and  walk  when 
she  is  lying  down.  To  apply  a  rubber  bag  in  the  vagina.  Hot 
vaginal  injection  carried  up  to  the  cervix.  Sulphate  of  quinine 
0.50  to  one  gramme.  Interrupted  current  of  electricity  to  the 
uterus.  To  practice  rupture  of  the  membranes  when  the  dilatation 
has  passed  three  finger's  breadths,  when  the  presentation  is  normal 
and  the  head  deeply  engaged.  Never  forget  ergot  at  this  moment. 
Perversions  of  the  contractions  is  manifested  in  their  irregularity 
or  by  their  permanence  in  uterine  tetanus.  Chloroform  or  chloral 
usually  re-establishes  then  normal  intermittence. 


Fig.  361. — Retrodeviation  of  the  gravid  uterus  (Schatz).     Ve,  bladder; 
Ur,  urethra;  A,  anus. 

15.  Uterine  deviations. — At  the  end  of  pregnancy,  the  body  of  the 
uterus  is  often  deviated  forward,  when  previous  gestations  have 
weakened  the  abdominal  wall  and  produced  a  more  or  less  pro- 
nounced eventration.  An  appropriate  belt  and,  during  accouche- 
ment, the  horizontal  decubitus  is  sufficient  to  correct  this  deviation. 
Lateral  deviations  are  rarely  causes  of  dystocia.  They  will  be 
remedied  by  the  position  of  the  woman.  The  most  important  dis- 
placement, on  account  of  the  disturbances  it  is  capable  of  causing, 
is  retrodeviation  (Fig.  361) .  The  beginning  of  a  retrodeviation  is 
sometimes  slow  and  insidious,  sometimes  sudden  in  consequence 


Diseases  of  the  Genital  System, 


:;i:; 


of  an  effort  or  a  fall.  The  most  important  Bymptom  marking  retro- 
deviation ia  the  retention  of  urine,  which  may  be  complete  or  in- 
complete. The  rectal  compression  by  the  body  of  the  uterus  ca 
an  obstinate  constipation.  The  pressure  of  the  uterus  on  the 
perinseum  produces  a  sensation  of  weighl  thai  is  sometimes  very 
painful. 


P 


First  month. 


Fig.  362. — A,  uterus  free  ;   B,  uterus  incarcerated. 
Second  month.  Third  month.  Fourth  month. 


|^$> 


Fig.  363.— Retrodeviation  of  conception.     Spontaneous  reduction  at  fourth  month. 


Fig.  364. — Retrodeviation  of  conception.     Incarceration  at  the  fourth  month. 


Fig.  365. — Uterus  normal  at  conception,  inclining  progressively  backward 
and  incarcerated  the  fourth  month. 


Fig.  366. — Uterus  normal  at  conception,  inclining  suddenly  backward 
at  the  fourth  month  and  becoming  incarcerated. 


314  Diseases  of  the  Genital  System. 

It  is  important  in  the  evolution  of  retrodeviation  to  distinguish 
two  periods  or  states :  First,  the  period  during  which  the  uterus, 
not  yet  large,  may  be  replaced  in  its  normal  position  with  relative 
facility ;  second,  the  period  of  incarceration  or  impaction,  during 
which  the  uterus,  now  too  large,  cannot  swing  in  the  pelvic 
excavation  and  is  found  imprisoned.  The  period  of  incarceration 
is  produced  at  the  beginning  of  the  fourth  month  of  pregnancy 
(Figs.  362-366). 


Fig.  367. — Sacciform  dilatation  (Oldham). 

If  the  reduction  of  the  retrodeviation  takes  place  before  incar- 
ceration the  disturbances  produced  by  the  displacement  are  few. 
But  at  the  moment  when  incarceration  is  produced  important 
conditions  arise  which  may  terminate  in  various  ways : 

a.  Termination  icith  regard  to  the  deviation.  —  There  may  be  ter- 
mination in  spontaneous  or  induced  abortion.  When  abortion  does 
not  occur  there  may  be : 

1.  Reduction  in  consequence  of  repeated  catheterism  or  of  a 
special  intervention  intended  to  return  the  uterus  to  place. 

2.  Semi-reduction  (sacciform  dilatation)  (Fig.  367). — This  is  pro- 
duced by  progressive  development  of  the  wall  of  the  uterus  toward 
the  abdomen  (Fig.  368).  This  variety  should  be  distinguished  in  a 
pathogenetic  point  of  new  from  that  produced  at  the  end  of  preg- 
nancy by  ampliation  of  the  posterior  inferior  segment  of  the  uterus 
(Fig.' 369). 


Diseases  of  the  Genital  System. 


31/ 


3.  No  reduction. — The  child  dies  and  abortion  is  produced  after  a 
variable  time. 

I.  Termination  with  regard  t<>  the  patient. — Cure  after  reduction  or 
abortion.  Death  may  be  produced  before  or  after  reduction,  by 
septicaemia,  by  gangrenous  cystitis,  by  rupture  of  the  posterior  wall 
of  the  vagina,  of  the  rectum,  and  of  the  perimeum,  or  by  a  renal 
complication. 


Fig.  36S. — Sacciform  dilatation 
following  retrodeviation. 


FlG.  369. — Sacciform  dilatation  without 
previous  retrodeviation. 


Treatment. — When  incarceration  does  not  exist  attempt  should  be 
made  to  replace  the  uterus  by  slight  pressure  with  the  finger  in  the 
posterior  cul-de-sac.  For  the  same  purpose  the  patient  is  ordered 
to  assume  the  genu-pectoral  position  for  twenty  minutes  every 
morning  and  night.  When  incarceration  exists  there  are  three 
methods  to  follow,  expectation,  manual  or  instrumental  reduction, 
induced  abortion. 

1.  Expectation. —  Simple  expectation,  aided  by  regular  eathe- 
terism,  three  times  a  day,  is  sufficient  in  the  majority  of  cases  to 
cause  spontaneous  reduction,  in  eight  to  fifteen  days.  Thus,  except 
in  serious  accidents,  this  is  the  method  to  follow.  But  the  necessity 
of  rectal  evacuations  should  not  be  forgotten. 

2.  Reduction. — Manual  or  digital  reduction  will  be  attempted  with 
the  woman  in  the  dorsal,  lateral,  or  genu-pectoral  position.  In 
difficult  cases  chloroform  should  be  employed.  A  prolonged  bath 
will  be  favorable  as  a  preparation  for  attempts  at  reduction.  Some- 
times the  introduction  of  a  rubber  bag  into  the  rectum,  leaving  it 
inflated  for  twenty-four  hours,  causes  gradual  reduction. 

3.  Induced  abortion. — In  cases  where  reduction  is  impossible  and 
where  grave  symptoms  necessitate  prompt  intervention,  abortion 
should  be  induced  at  once. 


316 


Diseases  of  the  Genital  System. 


16.  Uterine  prolapsus. — Complete  or  incomplete  prolapsus  may 
exist  at  any  period  of  term  (Fig.  370).  Treatment :  Reduction  of 
the  uterus  with  its  contents ;  if  this  is  impossible,  previous  evacu- 
ation (induced  abortion)  with  final  reduction. 


_  Vagina 


-Ulceration* 


Fig.  370. — Prolapsus  of  the  gravid  uterus  (Budin). 

17.   Uterine  ruptures. — Uterine  ruptures  may  be  divided: 
In  view  of  the  situation,  into  : 

1.  Intra- vaginal  (lacerations). 

2.  Supra-vaginal,  affecting  the  cervix,  the  isthmus  or  the  body 
(this  variety  only  will  be  taken  under  consideration  here). 

In  view  of  the  degree,  into : 

1.  Incomplete. — Peritonaeum  intact. 

a.  Intra-muscular. — Simple  separation,  not  attacking  the  whole 
thickness  of  the  muscular  wall. 

//.  Supra-muscular. — All  the  muscular  wall  is  attacked,  but  the 
peritonaeum,  the  bladder  and  the  broad  ligaments  are  not  involved. 

2.  Complete. — Peritonaeum  involved.  The  uterine  cavity  is  in 
direct  communication  with  the  peritonaeal  cavity. 

3.  Complicated. — Wound  of  a  contiguous  organ.  Opening  of  the 
bladder  or  intestine. 

In  view  of  the  date  of  the  puerperal  state,  into : 

1.  Piuptures  of  pregnancy. 

2.  Ruptures  of  labor. 

3.  Ruptures  of  post-partum. 


Diseases  of  the  Genital  System.  317 

Ruptures  of  pregnancy  and  those  of  post-partum  are  relatively 
rare  and  result  in  mosl  cases  from  traumatism.  Their  study  pre- 
sents only  a  secondary  interest  and  we  Bhall  confine  this  description 
to  the  ruptun-  of  labor.     Frequency,  1  per  1000  accouchements. 

JStiology  and  pathogeny. — Ruptures  at  the  moment  of  labor  may 
be: 

1.  Traumatic. — Abdominal  traumatism,  blow  on  the  abdominal 
wall,  penetrating  wound.  Intra-uterine  traumatism,  version,  for- 
ceps, embryotomy,  etc. 

2.  Spontaneous. — Accouchement,  with  regard  to  the  uterus  alone, 
is  the  struggle  between  the  uterine  muscle  and  the  obstacles  which 
oppose  the  exit  of  the  foetus,  a  veritable  duel  in  which  the  victory 
generally  remains  with  the  uterus;  if  not,  the  exhausted  muscle, 
thinned  by  the  struggle,  is  ruptured  and  the  accident  we  study 
occurs. 

It  is  important  to  know  : 

The  causes  of  this  exaggerated  struggle. 

The  circumstances  which  favor  the  rupture. 

Cause*  of  the  exaggerated  struggle. — Periuterine,  pelvic  deformity, 
tumor  of  the  contiguous  tissues.  Uterine,  obliquity  of  the  uterus, 
rigidity  of  the  cervix.  Intra-uterine,  exaggerated  size  of  the  fcetu?, 
hydrocephalus,  monstrosity,  vicious  presentation. 

Circumstances  which  furor  rupture. — 

1.  Uterine  causes. 

Pathological  uterus. — Thinning  of  a  part  of  the  wall,  partial  de- 
generation, malformation,  cicatrix. 

Uterus  rendered  pathological. — By  ergot,  by  intra-uterine  irritation 
(introduction  of  the  hand  or  of  an  instrument). 

Normal  uterus. — The  progressive  thinning  of  the  inferior  segment 
may  be  such  (Fig.  371)  that  at  a  given  moment  it  causes  rupture. 

2.  Periuterine  causes. — Projection  of  the  promontory.  Abnormal 
projections  of  the  pelvis  (exostoses).     Yulvo-vaginal  atresia. 

3.  Intra-uterine  causes. — Projection  of  a  hand  or  foot.  Osseous 
splinters  in  consequence  of  embryotomy. 

Symptoms. — The  woman  suddenly  feels  a  sharp  pain  in  the  ab- 
domen and  sometimes  a  sensation  of  internal  tearing.  Following 
rupture  there  is  a  sensation  of  relative  relief.  The  pains,  however, 
quickly  return,  either  as  uterine  contractions  or  under  the  form  of 
peritonitis  resulting  from  the  rupture. 

In  direct  examination  of  the  woman  different  cases  may  present : 

1.  The  fetus  remains  in  the  uterus. — Direct  examination  furnishes 
scanty  information.  At  the  level  of  the  rupture  an  unequal  region 
is  felt,  very  painful  to  pressure. 

2.  The  fetus  has  passed  completely  or  incompletely  into  the  peri- 
tonaal  cavity. — By  palpation  one  rinds  above  the  tumor  formed  by 


318  Diseases  of  the  Bony  Pelvis. 

the  uterus,  the  foetus  making  a  more  or  less  notable  projection. 
Auscultation,  silence.  Digital  examination,  the  uterine  orifice 
does  not  present  the  foetus. 


Fig.  371., — Thinning  of  the  inferior  segment  of  the  uterus, 
previous  to  rupture  (Bandl). 

Thejoetus  has  been  expelled. — Accouchement  is  terminated  except 
the  delivery  of  the  appendages.  Intra-uterine  touch  alone  can  give 
in  such  cases  valuable  information.  Eupture  renders  expulsion  of 
the  appendages  impossible  and  as  artificial  delivery  thus  becomes 
necessary  it  is  by  introducing  the  hand  into  the  uterus  that  the 
accident  is  perceived. 

The  treatment  is  preventive  and  curative. 

Preventive,  in  all  cases  of  serious  dystocia,  when  the  uterine  con- 
tractions are  energetic,  by  diminishing  the  pains  by  the  use  of 
chloroform  and  by  aiding  the  uterus  as  much  as  possible. 

Curative. 

a.  Before  accouchement. — 1.  The  foetus  is  in  the  uterus. — Terminate 
accouchement  by  version,  extraction,  or  forceps,  provided  the  open- 
ing of  the  uterine  orifice  is  sufficient ,  if  not,  act  as  in  the  following 
case. 

2.  The  foetus  is  partly  or  completely  in  the  peritonceal  cavity. — 
Laparotomy  is  the  wisest  course  in  all  cases.  In  cases  of  too 
extensive  laceration  of  the  uterus  Porro's  operation  may  be  per- 
formed. 

18.  Uterine  tumors. — Cancer  has  been  studied  in  relation  to  the 
cervix.  We  have  only  to  deal  with  the  fibromata  here.  They  are 
classified  as  follows : 


Diseases  of  the  Bony  Pelvis. 


319 


1.  Interstitial  (Fig.  372) : 

1.  Of  the  body. 

2.  Of  the  cervix. 


Fig.  377. 


2.  Of  the  internal  surface  of  the  uterus  (submucous). 
1.  Of  the  somatic  cavity  : 

A.  Somatic  habitat  (Fig.  373). 

B.  Cervical  habitat  (Fig.  374). 

C.  Vaginal  habitat  (Fig.  375). 


320  Diseases  of  the  Genital  System. 

2.  Of  the  cervical  cavity  : 

A.  Cervical  habitat  (Fig.  376). 

B.  Vaginal  habitat  (Fig.  377). 


Bladder. 


Fig.  378. 

3.  Of  the  external  surface  of  the  uterus.  .  k 

1.  Anterior  wall  (Fig.  378) : 

A.  Body. 

1.  Subperitoneal  fibromata: 

B.  Cervix. 

1.  Subperitoneal. 

2.  Subvesical. 

3.  Intra- vaginal, 

2.  Lateral  wall  (Fig.  379) : 

A.  Body. 

1.  Subperitoneal. 

2.  Intra-ligamentous. 

B.  Cervix. 

1.  Intra-ligamentous. 

2.  Intra-vaginal. 

3.  Posterior  wall  (Fig.  380) : 

A.  Body. 

1.  Subperitoneal. 

B.  Cervix. 

1.  Subperitoneal. 

2.  Intra-vaginal. 

In  view  of  dystosia,  however,  we  may  again  divide  the  fibromata 
into : 

Lactero- superior  fibromata. 
Fibromata  previa. 


1 1   .  ises  of  the  Genital  System. 


321 


The  latero-superior  cavity  has  a  certain  degree  of  interest  in  ob- 
stetrics, for  the  tumor  may  interfere  with  pregnancy  by  it-  size  or 

by  its  situation  near  the  placenta.  The  importance  of  fibroma 
previa  is,  however,  in  a  practical  point  of  view,  much  more  con- 
siderable. 


Fig.  379. 


Fig.  380. 

Every  fibroma  increases  in  size  and  is  subject  to  a  certain  degree 
of  softening  under  the  influence  of  gestation,  then  it  diminises  after 
accouchement.  Thus  even  a  small  tumor  may  become  a  serious 
obstacle  to  accouchement,  by  its  growth. 

Fibroma  praevia  (Fig.  381)  predisposes  to  premature  expulsion  of 
the  ovum,  to  vicious  presentations,  to  premature  rupture  of  the 
membranes,  to  procidence  of  the  limbs  or  of  the  cord  and  to  liaemor- 


322 


Diseases  of  the  Genital  System. 


rhages,  but  the  most  grave  consequence  is  the  difficulty  or  the  im- 
possibility of  accouchement. 


Fig.  381. — F,  fibroma  prsevia. 

The  management  of  labor  in  these  cases  consists  in : 

1.  Waiting,  when  the  life  of  the  child,  and  that  of  the  mother 
especially,  are  not  in  danger.  Accouchement  sometimes  is  termi- 
nated spontaneously  when  a  most  serious  prognosis  would  have  been 
given. 

2.  If  spontaneous  accouchement  is  impossible,  recourse  to  the 
forceps,  to  version,  or  to  extraction.  It  is  generally  better  to  deliver 
the  child  head  first  (forceps)  than  last  (manual  extraction). 

3.  In  grave  cases  where  the  forceps  and  manual  extraction  are 
insufficient  there  remain,  as  ultimate  resources,  the  extirpation  or 
the  pushing  up  of  the  fibroma,  embryotomy  and  Caesarian  operation. 

Pushing  up  the  fibroma  should  be  attempted  under  chloroform, 
but  this  has  chances  of  success  only  when  the  tumor  is  subperi- 
toneal, occupying  Douglas'  cul-de-sac. 

In  cases  of  intra-vaginal  fibromata,  extirpation  will  be  successful. 

Embryotomy  will  be  preferable  if  the  child  is  dead,  or  if,  with  a 
passage  sufficiently  large  for  convenient  use  of  the  instruments, 
pushing  up  the  tumor  or  its  ablation  is  impossible. 

Caesarian  operation  is  the  last  resource  that  we  are  obliged  to 
employ. 

19.  Hernias  of  the  bladder,  of  the  intestine,  and  of  the  omentum. — 
Cystocele  and  rectocele  do  not  demand  any  special  treatment  during 
Labor,  except  that  they  should  be  kept  reduced  as  much  as  possible. 


Diseases  of  the  Genital  System.  Wl'.i 

In  cases  of  inguinal,  crural  or  umbilical  hernia  of  the  intestine, 
with  or  without  omentum,  reduction  should  be  maintained  by  an 
appropriate  bandage.  The  efforts  of  the  patient  should  he  abridged 
by  the  forceps  or  by  extraction  during  the  period  of  expulsion. 


Fig.  382. — Cyst  of  the  broad  ligament.     T,  cyst;  U,  cervix; 
Va,  vagina  (Budin). 

20.  Tumors  of  the  ovary  and  its  vicinity.  —  Any  abdominal  tumor 
may  interrupt  the  normal  course  of  pregnancy  and  of  accouche- 
ment. Among  these,  cysts  of  the  ovary  and  of  the  broad  ligament 
are  especially  to  be  mentioned  on  account  of  their  relative  im- 
portance. The  cyst  may  fall  into  Douglas'  cul-de-sac  (Fig.  382)  and 
obstruct  accouchement.  Puncture,  then,  permits  us  to  remove  the 
obstacle.  During  pregnancy,  if  the  cyst  is  voliminous  and  there  is 
fear  of  serious  complications,  it  may  be  removed  by  ovariotomy. 


32-4  Diseases  and  Anomalies  of  the  Placenta. 


CHAPTER  XX, 


DISEASES   AND   ANOMALIES   OF   THE 
PLACENTA. 

1.  Placentitis. — Inflammation  of  the  placenta,  if  it  exists,  is  not 
yet  well  understood. 

2.  Atrophy  and  hypertrophy,  which  may  affect  the  whole  of  the 
placenta  or  each  element  in  particular,  are  without  consequence 
unless  accompanied  by  another  pathological  state. 

3.  Apoplexy  and  hemorrhage.  —  Placental  haemorrhages  or  apo- 
plexies of  maternal  origin  present  under  three  forms  :  1.  Sanguine- 
ous infiltration,  not  well  limited.  2.  Focus  with  irregular  walls. 
3.  Clearly  circumscribed  focus.  The  blood  thus  suffused  undergoes 
the  usual  evolution.  The  causes  are  cardiopathy,  albuminuria, 
infectious  disease,  traumatism,  fluxion  coincident  with  menstrual 
period.  Often  there  is  no  appreciable  cause.  It  results  in  arrest  of 
the  development  of  the  child,  in  its  possible  death,  or  in  abortion. 
The  treatment  is  nul,  except  that  directed  to  the  supposed  cause. 
In  women,  who,  during  pregnancy,  have  menstrually  congestive 
symptoms  relating  to  the  uterus,  a  venesection  of  one  hundred  and 
fifty  to  two  hundred  grammes  might  be  repeated  at  each  menstrual 
period,  if  placental  haemorrhage  has  caused  interruption  of  previous 
pregnancies. 

4.  CEdcma  exists,  but  it  is  not  well  understood.  Its  practical 
importance  is  nul. 

5.  Fibro-fatty  degeneration  (sclerosis).  —  Under  the  influence  of 
endometritis,  of  syphilis,  or  most  often  from  an  unknown  cause,  the 
chorial  villi  are  invaded  by  fibro-fatty  degeneration;  the  process  is 
analogous  to  that  which  physiologically  destroys  the  villi  outside  the 
placental  zone.  The  placenta  is  thus  partially  or  completely  in- 
vaded from  the  periphery  toward  the  center.  The  result  is  the 
enfeeblement  or  the  death  of  the  foetus,  with  consequent  abortion. 
In  an  hystological  and  a  pathogenetic  point  of  view  this  degener- 
ation differs  from  placental  apoplexy  where  the  haemorrhage  is  the 
initial  phenomenon,  but  the  result  is  analogous.  Often  the  two 
processes  combine  to  cause  placental  destruction  and  death  of  the 
foetus.  Treatment:  Remedy  the  endometritis  and  all  pathological 
Btates  of  the  genital  organs. 

6.  ( 'alcareous  degenerations. — A  variety  of  petrification  at  dessemi- 
nated  points,  which  often  invades  the  placenta,  especially  at  its 


Diseases  and  Anomalies  of  the  Placenta.  825 

uterine  Burface.    ( lause,  unknown.    Influence  on  the  development  of 
the  foetus,  mil. 

7.  Albuminwric  alterations. — Whitish  plaques,  due  to  fibro-fatty 
degeneration. 

8.  Syphilitic  alterations. — Hypertrophy  of  the  villi.  Fibrous  de- 
generation.   Caseous  islets.    Gummata. 

9.  Cysts  are  frequent  at  the  foetal  Burface.  They  have  a  volume 
from  that  of  a  nut  to  that  of  ;i  mandarin.  Some,  of  haematic  origin, 
are  comprised  in  the  thickness  of  the  chorion.  Others,  serous,  formed 
by  a  Bubstance  analogous  to  Wharton's  jelly,  are  situated  betweeu 
the  chorion  and  the  amnion. 

10.  Solid  tumor*. — Fibromata.  Angiomatous  fibromata.  Fibrous 
myxomata.     Sarcomata.     Not  well  known.    Very  rare. 

11.  Adhesions. — When  expulsion  takes  place  before  term,  in  con- 
sequence of  haemorrhage,  of  degeneration,  and  most  often  without 
appreciable  cause,  there  exists  an  abnormal  adhesion  between  the 
uterus  and  the  placenta,  in  such  a  way  that  separation  is  difficult, 
almost  impossible.  The  adhesion  is  sometimes  so  great  that  after 
opening  the  uterus  post-mortem  it  is  impossible  to  detach  the 
placenta  without  the  aid  of  a  cutting  instrument.  The  manage- 
ment will  be  noted  apropos  of  the  complications  of  delivery. 

12.  Hydatiform  mole  is  the  term  used  to  designate  a  special 
degeneration  of  the  placenta  and  its  membranes.  Its  aspect  recall- 
that  of  a  hydatid  cyst.  The  hydatiform  mole  is  manifested  by 
three  principal  symptoms :  The  abnormal  development  of  the 
uterus,  the  uterine  haemorrhages,  and  the  escape  of  vesicles.  A 
detachment  of  vesicles  with  expulsion,  however,  is  rare,  unfortu- 
nately for  the  diagnosis. 

The  expelled  mole  presents  sometimes  under  the  form  of  a  mass 
of  vesicles  from  the  size  of  a  pinhead  to  that  of  a  nut,  not  united 
in  an  envelope ,  sometimes,  on  the  contrary,  they  are  surrounded 
by  the  membranes  of  the  ovum  (Fig.  383). 

It  is  now  admitted  that  the  hydatiform  mole  is  the  result  of  de- 
generation of  the  ovuline  appendages  and  m  particular  the  chorial 
villi.  However,  accord  is  not  yet  complete  on  the  nature  of  this 
alteration.  Robin  believes  it  to  be  a  hydropsy  of  each  villus. 
Yirchow  attributes  it  to  a  myoma  developing  at  the  expense  of  the 
elements  of  villus,  and  causing  cystic  degeneration. 

Treat  in  cut. — 1.  Before  expulsion,  simple  expectation.  If  haemor- 
rhage becomes  abundant,  vaginal tamponnement  becomes  necessary, 
performed,  we  shall  soon  see,  as  for  placenta  praevia.  Provocation 
of  labor  is  never  indicated. 

•2.  During  expulsion,  cervix  not  open,  same  conduct  >re. 

Cervix  open,  allow  spontaneous  expulsion,  unless  the]      is   grave 


326 


Diseases  and  Anomalies  of  the  Placenta. 


haemorrhage,  in  which  case  the  hand  will  be  introduced  into  the 
uterus  to  detach  and  to  remove  the  whole  mass. 

3.  After  expulsion,  rigorous  antisepsis.  If  the  flow  is  fetid  and 
contains  debris,  antiseptic  intra-uterine  injections  are  necessary, 
and  at  need  curetting,  completed  or  not  by  intra-uterine  tamponne- 
ment. 


Fig.  383. — Hydatiform  mole  (Boivin).     a,  decidua;  b,  chorion  and  amnion; 
d,  vesicls;  c  cf,  vesicles  of  different  size  and  form. 

13.  Vicious  insertion  of  the  placenta. — Placenta  pnevia. — Let  us 
divide  the  uterus  into  three  regions  by  two  parallel  planes,  the  in- 
ferior passing  at  eight  centimetres  from  the  internal  orifice,  the 
superior  at  eight  centimetres  from  the  superior  pole  of  the  uterus 
(Fig.  384).  Every  placenta,  which,  by  any  part  of  its  surface,  is 
inserted  below  the  plane  C  D,  is  an  inferior  polar  placenta  or  prsevia. 
Likewise  every  placenta  which,  by  any  part  of  its  extent,  is  inserted 
above  the  plane  A  B,  is  a  superior  polar  placenta.  Every  placenta 
inserted  between  these  two  planes  is  equatorial  or  median. 

In  one-third  of  all  cases  the  placenta  is  inferior  polar  or  prsevia. 
In  two-thirds  of  all  cases  the  placenta  is  of  the  superior  polar 
variety  (normal  or  physiological  insertion).  It  is  quite  exceptional 
for  the  placenta  to  be  whole  equatorial  (Fig.  385). 

It  will  then  be  seen  that  placenta  prsevia  is  far  from  being  rare, 


"Diseases  and  Anomalies  oj  tin-  Placenta. 


327 


and  thai  it  becomes  of  importance  by  having  its  insertion  on  the 
uterine  passage  which  the  foetus  must  follow  in  its  exit  from  the 
genital  organs. 


FlG.  3S4. — A  B,  constitutes  the  superior  polar  circle; 
C  D,  the  inferior  polar  circle. 


Fig.  3S5. — Different  varieties  of  insertion  of  the  placenta. 

There  are  four  varieties  of  placenta  praevia : 
1.  Central  placenta  pravia. — The  center  of  the  placenta  corre- 
sponds to  the  internal  orifice  of  the  uterus. 


328 


Diseases  and  Anomalies  of  the  Placenta. 


2.  Partial  placenta  pnevia. — Some  point  of  the  placenta,  interme- 
diate between  its  center  and  its  border,  corresponds  to  the  internal 
orifice  of  the  uterus. 

3.  Marginal  placenta  pravia. — The  edge  of  the  placenta  lies  over 
the  internal  orifice  of  the  uterus. 

4.  Lateral  placenta  prcevia. — The  edge  of  the  placenta  is  found  at 
from  one  to  eight  centimetres  from  the  internal  orifice.  All  the  in- 
ferior segment,  which  extends  circularly  to  eight  centimetres  from 
the  internal  orifice,  constitutes  the  zone  of  dangerous  insertion. 

The  frequency  progressively  increases  from  the  first  to  the  last 
variety.  Central  placenta  praevia  is  very  rare.  Lateral  placenta 
praevia  is  the  most  common. 

Exceptionally,  the  placenta  may  be  inserted  in  part  in  the  cervical 
cavity  (cervical  pregnancy).  The  accidents  and  the  management 
are  the  same  as  in  central  placenta  praevia. 

I  shall  only  mention  cases  in  which  there  is  a  vicious  insertion  of 
an  accessory  cotyledon  (Fig.  386).  The  management  is  the  same 
as  in  ordinary  placenta  praevia. 


Fig.  3S6. — Accessory  cotyledon  prsevia. 


In  examining  a  partial  or  central  placenta  praevia  soon  after  its 
expulsion,  three  zones  of  different  color  are  often  found  on  its 
uterine  surface :  a  central,  corresponding  to  the  internal  os,  pale 
and  yellowish;  an  intermediate,  reddish;  a  peripheral,  clearer. 
These  different  zones  arc  due  to  circulatory  modifications  of  the 
placenta  and  to  haemorrhages  during  pregnancy. 

The  foetus  is  usually  less  developed  than  in  the  normal  state. 


"Diseases  and  Anomalies  of  the  Placenta.  329 

Symptoms,  a.  Pregnancy. — Haemorrhage,  premature  rupture  of 
the  membranes,  vicious  presentations  of  the  foetus,  premature  ex- 
pulsion of  the  ovum,  are  four  possible  consequences  of  placenta 
previa.  Any  one  of  these  symptoms  allows  as  to  think  of  a  vicious 
insertion  of  the  placenta. 

Every  abundant  haemorrhage  occurring  during  the  last  three 
months  of  pregnancy,  when  there  has  been  no  rlow  of  blood  during 
the  first  six  months,  is  the  result  of  a  placenta  previa. 

Direct  examination  furnishes  certain  confirmative  signs.  Among 
these  there  are  two  of  importance,  the  thickening  of  the  inferior 
segment  of  the  uterus,  perceived  by  digital  examination,  and  the 
vagueness  which  accompanies  the  perception  of  ballottement  and 
which  results  from  the  presence  of  the  placenta.  The  other  signs  that 
it  is  pretended  can  be  gathered  by  palpation  (placental  doughyness), 
by  auscultation  (placental  souffle),  by  touch  (placental  pulsation 
of  Gendrin),  have  no  real  value. 

//.  Accouchement.  —  To  complete  the  history  of  placenta  previa 
during  the  period  of  opening  of  the  cervix,  it  is  sufficient  to  add  the 
signs  furnished  at  this  moment  by  digital  examination.  The  dila- 
tation of  the  external  os  permits  us  to  arrive  directly  on  the  placenta, 
in  case  the  insertion  is  partial  or  central.  An  unequal  spongy  body 
is  then  felt,  quite  different  from  the  membranes.  In  cases  of 
marginal  or  lateral  insertion,  the  placenta  can  only  be  felt  by  in- 
troducing the  finger  quite  far  into  the  uterus,  but  in  these  cases, 
when  the  sac  is  intact,  an  experienced  finger  can  devine  from  the 
thickness  and  the  inequalities  of  the  menbranes  the  vicinity  of  the 
placenta. 

During  labor,  if  premature  rupture  of  the  membranes  does  not 
take  place,  various  conditions  may  be  produced.  The  bag  of  waters 
may  be  regularly  formed  and  evolved  as  usual  (marginal  or  lateral 
insertion).  Again,  this  sac  is  constituted  in  part  by  the  placenta 
and  in  part  by  the  membranes  (partial  insertion),  rupture  occurs, 
by  preference,  at  the  union  of  the  placenta  and  the  membranes,  the 
placental  flap  being  thrown  aside  by  the  foetal  part  in  its  descent. 
Or,  finally,  the  placenta  alone  takes  the  place  of  the  bag  of  waters 
(central  insertion)  and  in  such  cases  two  circumstances  may  exist, 
either  the  foetus  passes  through  the  placenta,  rupturing  it,  or  it 
pushes  this  organ  before  it.  It  is  useless  to  say  that  in  the  latter 
case  the  death  of  the  fcetus  is  certain. 

Prognosis. — The  prognosis  is  grave  for  the  child,  for  about  50  per 
cent  of  fceti  succumb.  With  regard  to  the  mother,  antisepsis  has 
caused  a  great  diminution  in  the  danger  of  vicious  insertion,  since 
in  place  of  24  per  100  the  mortality  has  fallen  to  about  5  per  100. 

The  gravity  of  the  prognosis  depends  : 

Upon  the  moment  at  which  the  first  hemorrhage  appears —the 
earlier  it  takes  place  during  pregnancy  the  darker  is  the  prognosis, 


330  Diseases  and  Anomalies  of  the  Placenta. 

for,  in  general,  the  flow  is  as  much  more  precocious  as  the  placenta 
is  near  the  internal  os ; 

Upon  the  variety  of  the  insertion — the  more  the  insertion  ap- 
proaches the  central  variety  the  greater  is  its  gravity ; 

Upon  the  resistance  of  the  uterine  orifice  to  dilation ; 

Upon  the  intensity  of  the  uterine  contractions  ; 

Upon  the  fcetal  presentation ; 

Upon  the  death  of  the  child — the  death  of  the  foetus  occurring 
during  pregnancy,  retards  the  activity  of  the  utero-placental  circu- 
lation and  consequently  ameliorates  the  prognosis  of  the  haemor- 
rhage ; 

Upon  the  treatment — the  treatment  followed  plays  a  considerable 
role  with  regard  to  the  prognosis. 

Treatment. — The  methods  of  treatment  directed  against  placenta 
praevia  are  numerous.     They  are  abridged  in  the  following  table  : 

A.  Mother. 

I.  In  the  struggle  against  the  haemorrhage. 

1.  Method  of  Dubois,  ergot  (1836). 

2.  Method  of  Seyfert,  vaginal  injection  (1852). 

3.  Method  of  Leroux,  tampon  (1776). 
II.  To  open  the  cervix. 

4.  Method  of  Guillemeau,  forced  accouchement  (1571). 

5.  Method  of  Barnes,  rubber  bags  (1862). 

6.  Method  of  Greenhalgh,  induced  accouchement  (1865) . 

B.  Ovum. 

I.  Detachment  of  the  placenta. 

7.  Method  of  Simpson,  total  separation  (1844). 

8.  Method  of  Barnes,  partial  detachment  (1862). 

9.  Method  of  Bunsen,  partial  separation  (1839). 
I.  Drainage  of  the  liquor  amnii. 

10.  Method  of  Puzos,  rupture  of  the  membranes  (1759). 

11.  Method  of  Cohen,  rupture  after  placental  detachment 

(1855). 

12.  Method  of  Deventer,  perforation  of  placenta  (1734). 
III.  Action  on  the  fcetus. 

13.  Method  of  Kristeller,  fcetal  expression  (1865). 

14.  Method  of 

a.  Wigand,  external  cephalic  version  (1812). 
I.  Braxton  Hicks,  mixed  podalic  version  (1864). 

15.  Method  of  (no  special  name),  extraction  by  the  for- 

ceps, by  the  hand  (with  or  without  version),  or  by 
embryotomy. 


Diseases  and  Anomalies  of  the  Placenta. 


331 


It  is  impossible  to  treat  in  detail  the  description  <»f  these  different 
methods  and  I  shall  confine  the  discussion  to  those  that  arc  in- 
dispensable in  the  treatment  of  placenta  prfflvia  during  pregnancy, 


Fig.  3S7. — Gariel's  pessary. 

accouchement,  and  delivery  of  the  appendages.  In  all  the  thera- 
peutic measures  it  is  the  genital  haemorrhage  that  is  always  in  view, 
which  constitutes  the  principal  accident  of  the  vicious  insertion  and 
against  which  the  treatment  should  be  directed. 


Fig.  3SS. — Tampon  applied.     A,  deep  rolls  furnished  with  a  thread; 
B,  superficial  free  rolls;    C,  layer  of  charpie;   D,  T  bandage. 

a.  Pregnancy. — If  the  haemorrhage  be  slight  simple  expectation  is 
necessary ;  if,  on  the  contrary,  it  be  serious,  recourse  should  be  had 
first  to  vaginal  tampoimement  (Fig.  388),  then,  if  this   fail,  to 


332 


Diseases  and  Anomalies  of  the  Placenta. 


rupture  of  the  membranes,  preceded  or  followed,  at  need,  by  the 
application  of  Barnes'  rubber  dilator.  The  most  simple  means  for 
vaginal  tamponnement  is  Gariel's  pessary  (Fig.  387).  But  if  the 
inflated  rubber-bag  is  not  sufficient,  the  more  complicated  method 
of  packing  the  vagina  with  rolls  of  absorbent  cotton  or  charpie  be- 
comes at  once  necessary.  In  the  place  of  these  I  prefer  strips  of 
iodoform  gauze.  After  application  the  tampon  is  fixed  in  place 
and  supported  by  a  T  bandage  (Fig.  389). 


Fig.  389. — T  bandage  holding  the  tampon  (Bailly).    c  c,  the  two  ends  of  the 
bandage  are  turned  back  leaving  the  abdomen  completely  free. 

If,  in  spite  of  the  application  of  the  tampon,  the  haemorrhage 
continues  and  consequently  becomes  menacing,  more  active 
measures  are  necessary,  that  is,  the  interruption  of  pregnancy  by 
a  premature  accouchement.     Two  cases  may  present : 

(1).  Where  the  membranes  are  easily  accessible. — Multiparas,  with 
gaping  cervix  and  with  a  marginal  or  a  partial  insertion  of  the 
placenta.  The  membranes  can  then  be  largely  ruptured  with  the 
nail  or  a  blunt  instrument,  so  as  to  free  the  placental  border  to  a 
sufficiently  large  extent,  after  being  previously  assured  that  there 
exists  a  presentation  of  the  vertex  or  breech.  Any  other  pre- 
sentation than  that  of  the  vertex  should  first  be  converted  into  a 
breech  by  external  or  mixed  manoeuvres,  and  one  of  the  lower 
limbs  drawn  into  the  uterine  opening  as  soon  as  possible,  by  the 
method  of  Braxton  Hicks  soon  to  be  described.  In  cases  of  vertex 
presentation,  after  the  rapture  of  the  membranes,  a  Barnes'  dilator 
(Fig.  390)  will  be  applied  in  the  cervix,  so  as  to  induce  and  to 
hasten  labor. 

(2).  The  membranes  are  not  easily  accessible. — Primiparse,  with  a 
closed  cervix,  and  with  partial  or  central  insertion  of  the  placenta. 


Diseases  and  Anomalies  oj  the  Placenta, 


:;:;:; 


Iii  -urh  cases,  the  dilatation  of  the  cervix  is  begun  with  a  Barnes1 
rubber-bag,  preceded  at  need  by  the  introduction  of  the  finger  to 
Facilitate  the  passage  of  the  dilator.  At  the  end  of  .some  time  the 
rubber  sac  is  withdrawn,  and,  if  the  membranes  ar<  accessible, 
they  are  ruptured,  as  in  the  preceding  case.  If  the  opening  of  the 
cervix  is  still  insufficient,  a  dilator  of  larger  size  should  he  applied 
and  after  another  interval  the  membranes  will  again  be  -ought.  In 
oases  of  inaccessible  membranes,  Cohen's  method  consists  in  de- 
taching the  placenta  with  the  fingers  in  a  given  direction  until  the 
membranes  are  found  and  perforated,  liberating  a  placental  flap 
which  can  be  applied  against  the  uterine  wall;  the  difficulty  in  this 
theory  consists  in  devining  the  side  of  the  placenta  at  which  will  be 
found  the  shortest  way  to  the  appendages. 


FlG.  390. — Barnes'  dilators. 


b.  Labor. — Intervention  should  have  place  only  when  the  hemor- 
rhage is  serious.  Let  us  distinguish  two  cases,  presentation  of  the 
vertex  and  presentation  other  than  the  vertex. 

1.  The  vertex  presents. — The  best  and  most  simple  method  is  that 
of  Puzos,  that  is,  artificial  rupture  of  the  membranes  followed  by 
the  application  of  Barnes'  dilator  when  the  dilatation  is  less  than 
two  finger's  breadth.  If  the  membranes  are  inaccessible  the  pro- 
cedure is  commenced  by  the  application  of  Barnes'  dilator,  as  has 
been  indicated  in  the  treatment  during  pregnancy. 

2.  Presentation  other  than  vertex. — In  such  cases  Braxton  HicKs' 
method  should  be  resorted  to ;  if  the  breech  presents  it  is  sufficient 
to  draw  a  foot  down  into  the  pelvis ;  if  not,  after  previous  rupture 
of  the  membranes,  podalic  version  is  performed  by  mixed  ma- 
noeuvres, terminating  in  drawing  a  foot  down.  ^Yhen  dilatation  is 
insufficient,  or  the  membranes  inaccessible,  a  Barnes'  dilator  is 
applied,  as  before,  to  facilitate  the  intervention  by  a  previous  dila- 
tation. 

If  Puzos'  method  or  that  of  Braxton  Hicks  does  not  succeed  in 


334  Diseases  and  Anomalies  of  the  Placenta. 

arresting  the  litem  on  hage,  which  is  quite  exceptional,  and  if  the 
condition  of  the  woman  appears  serious,  one  should  have  recourse 
to  forced  accouchement  (method  of  Guillemeau).  This  method 
consists  in  applying  the  forceps  on  the  vertex  as  soon  as  the  dila- 
tation of  the  cervix  will  permit  the  introduction  of  the  blades,  or  in 
making  extraction  as  soon  as  a  foot  can  be  brought  into  the  vagina. 
But  forced  accouchement  should  only  rarely  be  practiced  on 
account  of  the  uterine  lacerations  to  which  it  exposes. 

c.  Delivery  of  the  appendages. — If  a  haemorrhage  occurs  at  this 
moment,  the  usual  conduct  in  such  cases  is  followed. 

d.  Stimulant  and  reparative  treatment. — When  the  woman  becomes 
anaemic  in  consequence  of  an  abundant  haemorrhage,  susceptible 
even  after  delivery  of  exposure  to  fatal  syncope,  one  or  more  of 
three  stimulants  should  be  used  —  alcohol  internally,  ether  subcu- 
taneously,  heat  to  the  periphery  and  internally  at  need  (hot  drinks). 

Finally,  in  grave  cases  transfusion  of  blood  should  be  used,  but 
in  place  of  the  ordinary  transfusion,  which  requires  a  special  ap- 
paratus, the  auto-infusion  of  Dr.  Prouff  should  be  used.  This  con- 
sists in  compressing  the  lower  limbs,  and  the  upper  if  necessary, 
by  a  rubber  band,  pushing  the  blood  from  the  extremities  toward 
the  trunk.  The  compression  of  each  lower  limb  causes  the  reflex 
of  120  to  150  grammes  of  blood,  equivalent  to  a  transfusion  of  the 
same  amount  of  blood  (about  three  hundred  grammes  for  both  lower 
linibs). 


Diseases  of  the  Ovuline  Envelopes.  :;:».", 


CHAPTER  XXI. 


DISEASES   OF    THE    OVULINE   ENVELOPES. 

1.  Amnion. — Inflammation  of  the  amnion  is  generally  admitted. 
The  result  of  this  may  be  the  augmentation  of  the  liquor  amnii  and 
the  formation  of  amniotic  hands  connecting  the  surface  of  the 
amnion  and  the  fcetus. 

2.  Chorion. — Besides  the  hydatiform  mole,  already  noted,  there 
is  observed  either  an  hypertrophy  of  the  villi  or  an  hypertrophy  as 
a  whole  with  numerous  nodules  (chronic  inflammation). 

3.  Deciduas. — Inflammation  of  the  connective  tissue  framework 
produces  diffuse  endometritis  ;  that  of  the  cells  of  the  decidua,  poly- 
poid endometritis,  that  of  the  glands,  cystic  endometritis.  These 
various  varieties  of  endometrites  which  especially  affect  the  uterine 
and  the  utero-placental  deciduas  are  a  cause  of  abortion.  Atrophy 
of  the  decidua,  which  has  been  considered  as  a  possible  cause  of 
abortion,  is  scarcely  known. 

Hyd/rorrhcea  occurs  after  the  second  month  of  pregnancy,  most 
often  during  the  last  three  months,  as  a  sudden  loss  of  a  liquid 
analogous  to  that  contained  by  the  amnion.  Sometimes  its  flow  is 
remittent,  sometimes  intermittent,  and  after  each  abundant  flow  of 
liquid  the  patient  notes  a  diminution  in  the  size  of  the  abdomen. 
This  aqueous  loss  comes  from  the  ovum  and  it  terminates  in  one  of 
two  ways  :  either  the  flow  ceases  and  pregnancy  continues  its  course 
to  normal  term,  or  there  is  premature  expulsion  of  the  ovum.  In  a 
pathological  point  of  view,  two  varieties  of  hydrorrhcea  are  accepted 
to-day.  One,  without  rupture  of  the  ovuin,  is  a  decidual  hydrorrhoea, 
caused  by  a  more  or  less  localized  inflammation  of  the  decidua  and 
its  glands.  The  other  is  an  amniotic  hydrorrhcea  constituted  by  a 
premature  rupture  of  the  membranes. 

The  treatment  of  hydrorrhcea  consists,  in  part,  of  repose  in  bed 
or  in  a  recumbent  position,  in  part  of  quieting  the  uterus  by  vibur- 
num prunifolium  or  opiates,  as  if  in  menacing  abortion.  This  pro- 
longation is  only  in  the  interest  of  the  fcetus  and  will  not  be  carried 
out  if  it  is  dead. 

4.  Cord. — The  length  of  the  cord,  which  measures  on  the  average 
a  half  metre,  between  0  and  3  metres.  Excess  of  length  exposes  to 
procidence  and  to  circles  around  the  child  ;  brevity,  to  more  serious 
consequences.     During  pregnancy  shortness  of  the  cord  may  be  the 


336  Diseases  of  the  Ovuline  Envelopes. 

cause  of  a  sharp  pain  in  a  localized  region  of  the  uterus,  of  a  vicious 
presentation,  and  sometimes  of  detachment  of  the  placenta,  a  source 
of  hemorrhage.  During  labor  the  same  disadvantages  may  be 
observed  and  also  a  certain  slowness  in  the  dilatation  of  the  cervix, 
due,  without  doubt,  to  the  obstruction  to  the  free  descent  of  the 
foetus.  It  is  then  sometimes  necessary  to  use  manual  extraction 
or  the  forceps,  with  the  possible  consequence  of  death  of  the  foetus 
and  rupture  of  the  cord. 


Fig.  391. — Knot  of  Baudeloque  (Charpentier). 

Knots  in  the  cord,  which  form  under  the  influence  of  the  evolutions 
of  the  child,  may  present  varied  appearances  (Fig.  391).  Their 
practical  importance  is  nul,  for,  contrary  to  what  might  be  sup- 
posed, they  are  incapable  of  completely  interrupting  the  funicular 
circulation. 

Exaggerated  torsion  of  the  cord  on  itself  is  capable  of  causing  the 
death  of  the  foetus,  but  this  cause  should  be  considered  as  exceptional. 

Obstruction  of  the  funicular  vessels  may  also  be  caused  by  in- 
trinsic causes,  such  as  phlebitis  of  the  umbilical  vein,  malformation 
of  the  cord,  shortness,  tumors,  or  simple  stenosis  of  the  vessels. 

0.  Liquor  amnii. —  Hydramnios.  —  Whenever  the  quantity  of  the 
liquor  amnii  exceeds  one  thousand  grammes  we  have  hydropsy  of 
the  amnion.  It  occurs  in  the  proportion  of  one  to  one  hundred 
pregnancies.  In  a  general  way,  we  may  say  that  hydramnios  has  a 
pathogeny  analogous  to  all  the  hydropsies,  its  source  is  in  a  circu- 
latory obstruction.  With  regard  to  the  foetus,  we  recognize  three 
causes : 

1.  Syphilis,  which  acts  through  the  hepatic  or  the  placental  lesions 
which  it  causes,  both  being  a  source  of  circulatory  disturbances. 

2.  Malformations,  indicating  a  vice  in  the  constitution  of  the 
foetus,  in  which  the  circulation  becomes  insufficient. 

3.  Twin  pregnancy,  where  the  circulation  of  one  foetus  is  ob- 
structed by  the  more  vigorous.  Sometimes  the  two  circulations 
are  mutually  interrupted,  producing  hydramnios  of  both  amniotic 
membranes. 

With  regard  to  the  mother,  the  causes  are  the  same  as  those  which 


Diseases  of  the  Omdine  Envelopes.  337 

produce  dropsy,  cedema,  and  anasarca.     Thus  hydramnios  is  often 
seen  to  coincide  with  these  different  diseases  of  the  pregnant  woman. 

Symptoms.  —  Hydramnios  is  manifested  under  two  forms,  acute 
and  chronic. 

The  chronic  form  oegins  insiduously ;  the  exaggeration  in  the 
quantity  of  liquid  becomes  notable  after  the  fifth  or  sixth  month. 
The  abdomen  is  abnormally  developed.  There  are  abdominal  and 
lumbar  pains,  respiratory  obstruction,  and  very  clear  sensation  of 
the  active  movements  of  the  foetus. 

The  acute  form  produces  rapid  development  of  the  abdomen, 
giving  rise  to  the  same  physical  signs  as  the  preceding.  But  the 
functional  troubles  here  take  a  pronounced  gravity;  the  pains  are 
acute,  the  respiration  is  difficult,  the  face  is  bluish,  and  there  is 
frequent  and  obstinate  vomiting.  The  termination  takes  place  by 
death  (when  not  interrupted  by  active  intervention),  by  expulsion  of 
the  ovum,  or  by  transformation  into  the  chronic  form,  with  attenu- 
ation of  the  symptoms. 

The  chronic  form  is  relatively  benign,  but  it  exposes  to  premature 
accouchement,  to  vicious  presentations,  to  procidence  of  the  cord, 
and  to  slowness  of  labor. 

The  acute  form  is  grave  for  it  most  often  terminates  in  the  death 
of  the  woman  or  m  the  premature  expulsion  of  the  ovum.  In  hy- 
dramnios ot  both  varieties,  eclampsia  and  grave  haemorrhages  are 
to  be  feared. 

The  prognosis,  with  regard  to  the  child,  depends  as  much  on  the 
cause  of  the  hydramnios  (syphilis,  malformations,  etc.),  as  on  the 
hydropsy  itself. 

Treatment.  —  Chronic  form.  —  Simple  expectation  during  preg- 
nancy. At  the  moment  of  labor  the  membranes  should  be  ruptured 
early  in  cases  where  the  three  following  conditions  are  united :  slow 
contractions,  vertex  presentation  with  marked  engagement,  cervix 
effaced  and  offering  a  dilatation  of,  at  least,  two  fingers'  breadth. 

Acute  form. — If  the  rapidity  of  the  accidents  menace  the  patient's 
existence  we  are  authorized  to  have  recourse  to  a  capillary  puncture 
of  the  ovum  (through  the  abdomen  or  vagina)  or  to  an  induced  ac- 
couchement. 

Deficiency  of  the  liquor  amnii. — Hijpoamnios. — A  want  of  amniotic 
liquid  predisposes  to  deformations  of  the  foetus,  and  during  labor  to 
a  slow  and  difficult  progression  of  the  fcetus,  on  account  of  the 
drvness. 


338  Diseases  and  Death  of  the  Foetus. 


CHAPTER  XXII. 


DISEASES   AND    DEATH   OF   THE   FCETTJS. 
FCETAL   DYSTOCIA. 

1.  Excess  of  the  volume  of  the  foetus . — The  excess  of  the  volume  of 
the  fcetus  may  be  simple  or  pathological.  It  is  simple  when  there 
is  an  exaggeration  of  the  fcetal  development,  without  trace  of  disease. 
If  pathological,  it  comprehends  all  the  causes  capable  of  producing 
hypertrophy  of  a  fcetal  region;  such  are,  hydrocephalus,  hydro- 
thorax,  ascites,  tumors,  monstrosities,  etc.  Each  of  these  causes 
will  be  studied  separately.  First  we  shall  take  into  question  simple 
excess  of  volume. 

Simple  excess  of  volume  may  be  generalized  or  localized. 

It  is  generalized  when  a  well-proportioned  child  presents  a  de- 
velopment superior  to  that  ordinarily  observed.  In  the  place  of 
three  kilogrammes  it  weighs  four,  five,  or  even  more.  The  obstacle 
to  accouchement  i  ecomes  the  same  as  that  created  by  a  deformed 
pelvis  with  a  fcetus  of  normal  size  and,  at  the  moment  of  accouche- 
ment, the  management  will  be  the  same.  Some  women  present  an 
excess  of  foetal  volume  at  several  consecutive  pregnancies  and  the 
question  of  premature  accouchement  will  present  itself  in  such  cases, 
for  this  will  sometimes  be  the  only  way  of  having  a  living  child. 
The  epoch  at  which  this  should  take  place  will  be  fixed  by  the  study 
i  by  palpation)  of  the  relation  existing  between  the  size  of  the  head 
and  the  pelvic  canal. 

The  hypertrophy  is  localized  when  there  is  relative  excess  in  the 
volume  of  the  head,  of  the  shoulders,  or  of  the  breech.  The  excess 
of  the  volume  of  the  shoulders  is  the  only  one  proven.  It  may 
become  an  obstacle  to  accouchement  whether  the  head  presents 
first  or  last.  In  cases  of  presentation  of  the  vertex,  when  the  head 
no  longer  advances,  before  or  after  having  opened  the  vulva,  the 
-boulders  being  arrested  at  the  superior  or  at  the  median  strait,  the 
forceps  will  bring  the  head  outside  the  vulva.  Then  if  simple 
tractions  are  not  sufficient  to  cause  descent  of  the  shoulders,  the 
two  arms  should  be  successively  sought  and  brought  down,  the 
anterior  first.  The  shoulders  then  engage  without  difficulty  and 
the  child  may  be  extracted.  In  cases  of  the  head  coming  last,  the 
same  manoeuvres  should  be  used. 

•_!.   Hydropsies. — Hydrocephalus;  Iljidrofhorar ,•  Ascites. 
Hydrocephalus  is  constituted  by  an  abnormal  accumulation  of 
serous  liquid  in  the   cranial   cavity.     Hydrocephalus   may  exist 


Diseases  and  Death  <>/  tin-  I-'nins.  339 

alone  or  it  may  be  complicated  by  bydrorhachis,  Bpina  bifida  or 
Borne  other  foetal  malformation.  Tlie  size  of  the  bead  is  variable.  The 
increase  is  made  at  the  expense  of  the  cranial  vault  (Fig.  392).  Its 
frequency  is  about  1-2000.  Its  causes  are  not  well  known.  Syphilis, 
cretinism,  and  consanguinity  have  been  noted. 


Fig.  392. — Hydrocephalic  head,  retained  at  the  superior  strait  (Playfair). 

During  pregnancy  hydrocephalus  may  be  suspected  from  the 
size  of  the  head,  revealed  by  palpation.  In  general,  it  is  at  the 
moment  of  labor,  when  the  dilated  cervix  permits  access,  that  the 
diagnosis  becomes  possible.  It  will  then  be  made  when  the  head 
comes  first  by  the  recognition  of  large  fontanelles,  and  of  the  un- 
usual interval  between  the  sutures.  When  the  head  comes  last 
manual  exploration  leads  as  before  to  a  diagnosis  from  the  con- 
dition of  the  sutures. 

At  the  moment  of  labor  the  management  will  vary  according  as 
there  is  a  presentation  of  the  cephalic  or  of  the  cormic  ovoid. 

Presentation  of  the  cephalic  ovoid. — Expectation  until  complete  dila- 
tation is  the  rule.  If  the  head  does  not  engage  an  application  of 
the  forceps  should  be  attempted.  If  the  forceps  fail,  recourse  should 
be  had  to  capillary  puncture  of  the  cranium  through  a  suture  or  a 
fontanelle,  without  removing  the  forceps,  and  the  tractions  should 
again  be  resumed  after  evacuation  of  the  liquid.  Embryotomy  con- 
stitutes the  ultimate  resource. 

Presentation  of  the  cormic  ovoid. — The  difficulties  only  exist  for  the 
extraction  of  the  head.  This  will  be  successively  attempted  as 
above  by  the  aid  of  manual  tractions  after  the  evacuation  of  the 
liquid  or  after  embryotomy.  The  evacuation  of  the  fluid  may  be 
obtained  by  capillary  puncture  of  the  cranium,  or  by  Van  Huevel's 


340 


Diseases  and  Death  of  the.  Foetus. 


method  (Fig.  393)  which  consists  in  cutting  the  vertebral  column 
transversely  and  passing  a  sound  by  this  opening  through  the 
spinal  canal  into  the  cranium. 

Hiidrothorax  only  exists  as  a  complication  of  ascites. 


Fig.  393.— Evacuation  of  the  hydrocephalic  liquid  by  the  spinal 
canal  (Van  Huevel). 

Congenital  ascites  is  very  rare  and  most  often  coincides  with  a 
certain  degree  of  peritonitis.  The  diagnosis  can  only  be  made  at 
the  moment  of  labor,  when  there  exists  difficulty  in  the  extraction 
of  the  trunk.     Treatment :  evacuation  by  puncture. 

3.  Diseases  of  the  urinary  apparatus. — Eetention  of  urine,  which 
accompanies  imperforation  of  the  urethra,  may  produce  a  con- 
siderable distention  of  the  abdomen  (Fig.  394).  It  requires  the 
same  treatment  as  ascites. 

4.  Diseases  of  the  bones  and  of  the  articulations. —  Intra-uterine 
fracture  of  the  foetus  may  be  traumatic,  and  due  to  a  blow  affecting 
the  abdominal  region  of  the  mother,  or  spontaneous,  and  produced 
by  an  osseous  friability  caused  by  rachitis. 


Disi 


■uses  and  I  eath  of  the  Foetus. 


341 


Congenital  luxations  may  a'.tack  nearly  all  the  articulations  but 
those  of  tho  hip  joint  are  most  frequent.  The  spontaneous  luxations 
should  be  distinguished  from  those  produced  during  delivery  under 

the  influence  of  an  obstetrical  intervention  and  which  are  relatively 
rare. 


FlG.  394. — Retention  of  urine  (Portal). 

Intra-uterine  rachitis  causes  a  deformation  of  the  skeleton,  es- 
pecially resulting  in  shortness  of  the  upper  and  lower  limbs. 

Foetal  ankylosis  is  characterized  by  a  stiffness  of  the  majority  of 
the  articulations.  The  foetus  remains  as  if  congealed  in  the 
attitude  that  it  has  in  the  uterus.  From  this  proceeds  possible 
difficulties  for  extraction.  The  nature  of  these  ankyloses  is  still 
unknown. 

5.  Various  tumors. — Spina  bifida.  Sacral  hygroma.  Fibromata. 
Sarcomata.     Generalized  oedema  and  emphysema. 

6.  Congenital  amputation. — The  child  is  born  with  a  lower  or  an 
upper  member  missing.  The  divided  member  terminates  in  a 
regular  stump. 

There  are  two  theories  as  to  causation :  One,  that  the  circular 
strangulation  is  produced  by  the  umbilical  cord  or  by  a  pathological 
amniotic  band.  The  other,  that  the  production  of  a  cutaneous 
cicatrix  in  consequence  of  a  local  inflammation  results  in  a  pro- 
gressive stricture  terminating  in  gangrene  of  the  subjacent  parts  of 
the  limb. 

Death,  of  the  foetus. 

The  death  of  the  foetus  may  be  real  or  apparent.  The  death  is 
real  when  the  foetus  cannot  be  recalled  to  life  by  any  known 
means,  it  is  apparent  in  the  contrary  case.     Death  of  the  hetus 


342  Diseases  and  Death  of  the  Foetus. 

taking  place  during  pregnancy  will  be  necessarily  real  on  account 
of  the  time  that  separates  it  from  birth.  But  death  occurring 
during  labor  will  sometimes  be  real  and  sometimes  apparent 
according  to  the  duration  before  expulsion  and  also  to  the  cause 
producing  it.  It  will  be  seen,  then,  leaving  aside  the  etiological 
element,  that  during  accouchement  the  difference  between  real  and 
apparent  death  is  constituted  by  a  question  of  time ;  both  are  de- 
grees of  the  same  accident,  apparent  death  ends  in  real  death  if  it 
is  prolonged. 

These  intimate  connections  make  it  better  to  unite  in  the  same 
chapter  the  study  of  these  two  varieties  of  death;  after  having 
examined  their  aetiology,  common  to  both  at  least  during  labor,  we 
will  discuss  separately  the  pathological  anatomy,  the  symptoms, 
the  diagnosis,  the  prognosis,  and  the  treatment. 

^Etiology. 
I.  During  pregnancy. — Real  death. 

a.  Traumatic  causes : 

1.  Maternal  traumatism,  genital  or  perigenital. 

2.  Ovuline  traumatism,  attacking  the  ovum  or  the 

foetus  directly. 

b.  Non-traumatic  causes. 

Father: 

1.  General  state : 

1.  Advanced  age  ;  debilitation  from  excess. 

2.  Poisoning:  Lead,  tobacco,  alcohol. 

3.  Syphilis,  scrofulo-tuberculosis,  diabetes,  albu- 

minuria. 

2.  Localized  states : 

1.  Any  defect  of  the  genitals. 

Mother: 

1.  General  state : 

1.  The  same  as  for  the  father. 

2.  Any  grave  disease  occurring  during  pregnancy. 

2.  Localized  state : 

1.  Periuterine   or   uterine    affection   (including 

tumors). 

2.  Utero-placental  haemorrhage. 

Ovum: 

1.  Appendages : 

1.  Placenta:  Apoplexy,  degeneration,  hydatiform 

mole. 

2.  Cord :  Compression,  loops,  torsion,  knots. 


Diseases  and  Death  of  the  Foetus.  343 

2.  Foetus: 

1.  Various  diseases  of  the  foetus. 

2.  Vices  of  conformation. 

3.  Habitual  death. 

3.  Extra-uterine  pregnancy. 

II.  During  labor. — Real  or  apparent  death. 

a.  Traumatic  causes. 

1.  Maternal  traumatism,  genital  or  perigenital, 

attacking  the  uterus  through  the  abdominal 
wall  or  by  the  vagina. 

2.  Ovuline  traumatism  (version,  forceps,  embry- 

otomy). 

b.  Non-traumatic  causes. 

Mother: 

1.  General  conditions : 

1.  Eclampsia. 

2.  Asphyxia  or  grave  asystole. 

3.  Death  of  the  mother. 

4.  Any  grave  disease  capable  of  determining  pre- 

mature accouchement  may,  at  the  same  time, 
cause  the  death  of  the  foetus. 

2.  Localized  conditions : 

1.  Uterine  or  periuterine  affections  capable  of 

seriously  obstructing  accouchement.  Uterine 
tetanus. 

2.  Utero-placental  haemorrhages. 

Ovum: 

1.  Placenta:  Extensive  detachment. 

2.  Cord :  Compression,  loops,  torsion,  knots. 

3.  Foetus. 

Too  long  duration  of  labor.  Intra-cranial  effu- 
sion. Presentation  of  face:  compression  of 
the  vessels  of  the  neck.  Presentation  of  the 
breech:  slowness  of  extraction  of  the  head. 
In  general,  any  difficulty  of  accouchement 
proceeding  from  the  foetus 

I.  Real  death.— Pathological  anatomy.  —  The  foetus  having  suc- 
cumbed, if  it  is  still  in  the  embryotic  state,  may  undergo  a  complete 
dissolution  and  disappear ;  if  not,  it  becomes  macerated.  Mace- 
ration may  be  clearly  distinguished  from  putrefaction,  for  it  occurs 
without  odor,  without  the  production  of  gas,  and  does  not  expose 
the  woman  to  any  septicemic  accident. 

In  maceration  there  is  a  progressive  softening  of  all  the  organs. 
The  epidermis,  upraised  by  phlyctenular,  is  detached  to  a  greater 


344  Diseases  and  Death  of  the  Foetus. 

or  less  extent.  The  liquor  amnii  becomes,  successively,  reddish, 
greenish,  chocolate-colored,  and  grumous.  The  placenta  appears 
as  if  washed  out. 

Maceration  is  produced  when  the  membranes  are  intact  and  the 
foetus  isolated  in  the  amniotic  liquid.  In  cases  of  perforation  of  the 
membranes  and  access  of  air  to  tne  foetus,  putrefaction  takes  place. 

Mummification  is  a  variety  of  maceration  in  which  the  foetus 
becomes  desiccated. 

Lithopaeclion  is  only  produced  in  cases  of  extra-uterine  pregnancy. 

Symptoms. — a.  During  pregnancy. — 

1.  Interrogation. — Establishment  of  the  lacteal  secretion,  analo- 
gous to  that  occurring  after  delivery.  Cessation  of  the  sympathetic 
phenomena.  Diminution  of  albuminuria  in  cases  where  it  exists. 
Diminution  of  varices.  Cessation  of  the  foetal  movements,  when 
they  have  already  been  perceived.  Special  sensation  of  weight,  of 
an  inert  mass  in  the  abdomen. 

2.  Inspection. — No  special  sign. 

3.  Palpation. — The  sensations  furnished  by  the  foetus  become 
more  and  more  vague.  Uterus  stationary  or  diminishing  in  volume. 
Sometimes  a  sensation  of  crepitation  caused  by  the  over-riding  of 
the  bones  of  the  head. 

4.  Auscultation.  —  Foetal  silence.  Eustling  isochronous  with  the 
pulse  of  the  mother,  indicated  by  Stoltz  (?). 

5.  Digital  examination. — Furnishes  only  little  information  during 
pregnancy,  sometimes  permitting,  however,  the  perception  of  the 
mobility  and  even  the  crepitation  of  the  bones  of  the  cranium. 

h.  During  labor. — Same  results  as  during  pregnancy,  afforded  by 
interrogation,  palpation  and  auscultation. 

Inspection. — Flow  of  liquor  anmii,  greenish,  reddish  or  chocolate 
color. 

Digital  examination. — 

Vertex  presentation — over-riding  and  mobility  of  the  bones.  ~| 
Face  presentation — mouth,  no  suction.  T,  . ,        .        -  ,.    . 

Breech  presentation-anal  sphincter,  no  contraction.  f  EPldermic  exfoliation 

Thorax  presentation — hand,  no  movement. 

The  treatment  will  be  addressed  to  the  cause  that  is  supposed  to 
have  produced  the  death  of  the  foetus.  Syphilis  occupies  the  first 
rank  here.  Under  aetiology  I  have  mentioned  habitual  death  of  the 
foetus.  This  term  is  used  to  designate  the  death  of  the  foetus  occur- 
ring during  a  series  of  pregnancies  at  about  the  same  epoch.  The 
treatment  in  such  cases  consists  in  inducing  accouchement  some 
days  before  the  usual  period  at  which  the  foetus  succumbs,  to  allow 
delivery  of  a  living  and  viable  child.  That  is  to  say,  that  inter- 
vention will  be  useless  in  cases  where  the  habitual  death  occurs 
before  the  beginning  of  the  seventh  month. 


Diseases  and  Death  of  the  Foetus.  345 

11.  Apparent  death. — The  child  born  in  a  state  of  apparent  death 
pr<  -'Hi.-,  according  to  the  cases,  two  absolutely  distinct  appear- 
and 

It  sometimes  appears  violaceous,  all  the  peripheral  are 

engorged  with  blood,  the  pulsations  of  the  heart  are  clearly  per- 
ceptible; tii«'  prognosis  is  relatively  benign. 

It  sometimes  appears  white,  the  skin  seems  deprived  of  Mood,  the 
pulsations  of  the  heart  are  feeble,  sometimes  nul,  or  difficult  to  per- 
ceive; the  prognosis  is  relatively  grave. 

In  the  first  case  there  is  respiratory  syncope,  asphyxia,  properly 
so-called,  due  to  arrest  of  the  placental  function,  pulmonary  res]  1- 
ration  being  not  yet  established.  In  the  second  case  there  is  cardiac 
syncope,  complete  or  incomplete.  The  first  form  quickly  ends  in 
the  second,  the  respiratory  syncope  conducing  to  the  cardiac.  If 
the  cardiac  syncope  lasts  a  certain  length  of  time  (difficult  to  state 
precisely)  apparent  death  gives  place  to  real  death. 

At  birth,  the  absence  of  respiratory  movements  and  of  cries  in- 
dicates plainly  the  grave  state  in  which  the  child  is  found.  To  know 
if  the  death  is  real  or  apparent,  the  condition  of  the  heart  must  be 
observed  by  grasping  the  umbilical  portion  of  the  cord  or  by  applying 
the  hand  or  the  ear  on  the  precordial  region.  "Whenever  the  pul- 
sations are  perceptible,  death  is  only  apparent.  If  the  pulsations 
are  nul  insufflation  will  be  attempted  for  about  half  an  hour,  and  if 
after  this  time  no  pulsation  can  be  perceived  it  may  be  concluded 
that  death  is  real. 

Treatment.  —  The  mouth  and  the  pharynx  should  be  cleansed  of 
mucus  by  the  finger  covered  with  a  soft  cloth.  The  treatment  con- 
sists in  attempting  to  arouse  cardiac  action  by  insufflation,  or  by 
other  means  intended  to  re-establish  the  respiratory  function. 

a.  Methods  other  than  insufflation: 

1.  Bleeding  of  the  cord. — Generally  abandoned  at  present. 

*2.  Electricity. — Interupted  currents,  one  pole  on  the  vertebral 
column  at  the  upper  part  of  the  dorsal  region,  the  other  moved  over 
the  pectoral  region  from  side  to  side. 

3.  Cutaneous  excitation.  —  Simple  frictions,  alcohol  along  the 
vertebral  column,  flagellation,  hot  baths  or  alternately  hot  and  cold 
plunge  baths. 

b.  Insufflation. 

Indirect  insufflation. — 1.  Marshall  Hall. — The  child  is  laid  on  the 
abdomen,  then  turned  on  the  side  and  finally  given  a  sudden  move- 
ment replacing  it  in  its  first  position.  This  is  performed  fifteen  to 
twenty  times  a  minute. 

2.  Schultze. — The  child  is  grasped  by  the  shoulders,  the  abdomen 
turned  forward,  and  by  a  movement  through  the  arc  of  a  circle  it  is 
carried  upward,  as  if  turning  a  summersault,  then  it  is  lowered 


346 


Diseases  and  Death  of  the  Foetus. 


by  a  movement  in  the  opposite  direction.     The  elevation  produces 
expiration,  the  descent  inspiration. 

3.  Sylvester.— The  child  is  grasped  by  the  breech  and  the  neck 
and  given  a  sudden  movement,  parallel  to  itself,  of  elevation  (ex- 
piration) and  of  descent  (inspiration). 

4.  Howard.  —  Respiratory  movements  are  given  to  the  thorax, 
either  directly  by  the  hands  or  by  raising  and  lowering  the  arms. 

5.  "Woilez. — Spirophore,  a  case  enclosing  the  child  to  which  respi- 
ratory movements  can  be  given. 

All  these  methods  of  indirect  insufflation  afford  actual  service 
but  are  inferior  to  direct  insufflation. 


Fig.  395. — Chaussier-Depaul's  tube. 

Direct  insufflation  may  be  made  mouth  to  mouth  or  by  the  use 
of  the  laryngeal  tube.  As  the  former  method  is  often  repugnant 
insufflation  by  means  of  the  laryngeal  tube  is  generally  preferred. 
For  this  purpose  Chaussier  has  invented  a  metallic  tube  that  has 
been  slightly  modified  by  Depaul  (Fig.  395).  This  tube  is  intro- 
duced into  the  larynx  under  the  guidance  of  the  finger  (Fig.  396) 
and  serves  to  inflate  the  lungs. 


Fig.  396. — Application  of  the  insufflator  (Ribemont's  tube). 

How  long  should  insufflation  be  continued?     If  the  child  returns  to 
life  little  by  little,  as  indicated  by  the  increasing  frequence  of  the 


Diseases  and  Death  of  the  Foetus.  347 

spontaneous  inspirations,  the  insufflations  should  be  continued  until 
respiration  occurs  ten  to  fifteen  times  a  minute. 

Hut  if  the  nturn  to  life  is  slow  to  appear,  at  the  end  of  what 
Length  of  time  should  we  despair'?  The  management  may  be 
Bummed  up  in  the  following  propositions: 

1.  If  after  a  half  hour  of  insufflation,  the  pulsations  of  the  heart 
are  mil,  it  is  .useless  to  continue  ;  the  death  is  real. 

2.  When  the  cardiac  pulsations  exist,  if  after  an  hour  of  insuf- 
tlation  no  spontaneous  movement  of  respiration  is  produced,  tin 
efforts  may  be  discontinued,  for  this  ahsence  of  respiratory  move- 
ments indicates  that  the  child  has  undergone  some  lesion  incom- 
patible with  the  re-establishment  of  life. 

3.  If  after  two  hours  of  insufflation,  and  when  cardiac  pulsations 
and  some  spontaneous  respirations  exist,  the  movements  diminish- 
ing and  tending  to  disappear  as  soon  as  insufflation  is  interrupted, 
it  will  he  useless  to  continue  longer,  the  conditions  necessary  to 
life  being  wanting,  as  in  the  preceding  case 

Teratology. — I  shall  only  give  here  a  very  short  glance  at  tiiis 
question,  by  conforming  to  the  classification  of  Saint-Hilaire.  The 
teratology  comprises  the  hemiterias,  the  heterotaxias,  the  herma- 
phrodisms  and  the  monstrosities. 

1.  Hemiterias. — Among  the  principal  hemiterias  are  : 

Encephalocele,  meningocele,  spina  bifida.     Harelip. 

Imperforation  of  the  oesophagus,  of  the  anus,  of  the  urethra. 

Diaphragmatic  and  umbilical  hernias.     Cardiac  ectopia. 

Non-descent  of  the  testicles. 

Hypospadias.     Epispadias. 

Duplicity  of  the  uterus  and  of  the  vagina. 

Polymazia.     Polydactylism. 

Clubfoot. 

2.  Heterotaxias. — Total  or  partial  splanchnic  version.  The  organs 
occupy  a  position  other  than  normal. 

3.  Hermaphrodisms. — Hermaphrodism  is  designated  the  reuion, 
in  the  same  individual,  of  the  male  and  female  genital  organs,  one 
or  the  other  being  anatomically  or  physiologically  incomplete. 

4.  Monstrosities. 

a.  Simple  monsters,  in  which  a  limb  or  the  head  is  wanting. 
J).  Composite  monsters  formed  by  the  fusion  of  two  or  three  fceti 
simultaneously  developed  in  the  uterine  cavity. 


348 


Multiple  Pregnancy. 


CHAPTER  XXIII. 


MULTIPLE   PREGNANCY. 

Two  to  five  fceti  may  be  simultaneously  contained  in  the  uterine 
cavity.  Multiple  pregnancies  of  more  than  five  children  are  not 
clearly  proven.  In  the  study  of  multiple  pregnancy  we  shall  adopt 
the  following  plan : 

I.  Twins. 

A.  Pregnancy. 

B.  Accouchement. 

a.  Eutocia. 

b.  Dystocia. 

II.  Three  to  Jive  children  at  a  birth. 


Fig.  397. — Fceti  in  9  9. 

I.  Twins. — A.  Pregnancy. — Physiology. 

a.    Fecundation.  —  Sometimes  the   two   children   are   conceived 
simultaneously,  sometimes  there  is  a   variable   interval  between 


Multiple  Pregnancy. 


349 


them.     In  the  first  case  there  is  simultaneous  fecundation;  in  the 
second,  Buperfecundation  or  superimpregnation. 

Buperfecundation  is  subdivided  into  Buperovulation,  superembry- 
onnement,  superfcetation. 

Swperowdation. — The  two  successive  fecundations  very  near,  from 

some  hours  to  eight  days. 
Swperembryonnement. — The  two  successive  fecundations  art;  separ- 
ated hy  an  interval  of  eight  days  to  three  months. 
Superfcetation.  —  The  two   successive  fecundations   occur  at  an 
interval  greater  than  three  months. 


Fig.  398. — Fceti  in  6  6. 

The  first  two  varieties  are  beyond  doubt,  but  superfcetation  is  not 
generally  admitted,  for  at  this  moment  the  two  deciduas  being 
united,  communication  between  the  vagina  and  the  tubes  is  inter- 
rupted. 

I.  Disposition  of  the  fceti.- — The  various  dispositions  may  be  ar- 
ranged in  three  classes,  lateral,  where  the  twins  are  side  by  side ; 
antero-posterior,  one  before  the  other,  and  lastly,  superposed,  one 
above  the  other.  The  first  disposition  is  much  the  most  frequent, 
the  last  two  being  exceptional. 


350  Multiple  Pregnancy. 

I.  Lateral. 

1.  Fceti  in  9  9,*  the  two  heads  are  below,  one  generally  engaged, 
the  other  in  the  iliac  fossa  (Fig.  397). 

2.  Fceti  in  6  G,  the  two  breeches  are  below;  one  in  relation  with 
the  superior  strait,  the  other  in  the  iliac  fossa  (Fig.  398). 

3.  Fceti  in  6  9  or  in  9  6  (Fig.  399). 


Fig.  399, — Foeti  in  6  9  (Budin). 

II.  Anteroposterior. 

<1.  The  two  fceti  are  placed  one  before  the  other  (Fig.  400). 

III.  Superposed. 

5.  Fceti  in  T.  The  upper  foetus  lies  transversely  at  the  fundus  of 
the  uterus,  the  lower  is  vertical,  presenting  by  the  breech  or  by  the 
head  (Fig.  401). 

6.  Fceti  in  j,  inverted.  The  upper  foetus  is  vertical,  the  head 
below  or  above,  the  inferior  lies  transversely  in  the  pelvis  (Fig.  402). 

7.  Fceti  in  hammock.  The  two  fceti  are  transverse  one  above  the 
other  (Fig.  403). 

c.  Disposition  of  the  appendages. 

] .  Separation. —  The  two  ovuline  appendages  are  completely  dis- 

*  I  compare  the  foetus  to  the  figure  6,  the  rounded  part  representing  the  breech  and 
the  terminal  part  the  head. 


Multiple  Pregnancy. 


851 


Fig.  400. — Foeti  anteroposterior  (Budin). 


Fig.  401. — Foeti  in  T  (Budin). 


352 


Multiple  Pregnancy. 


Fig.  402. — Fceti  in  j,  (Budin). 


FlG.  403. — Foeti  in  hamnock  (Budin). 


Multiple  Pregnancy. 


353 


tinct.  The  .septum  which  separates  the  two  fceti  is  composed  of  the 
two  amnion-  ami  of  the  two  chorions,  between  which  some  elements 
of  the  decidua  may  be  interposed  (Fig.  404). 


Fig.  404. — Distinct  sacs:  chorio-amniotic  septum. 

2.  Attachment. — The  two  placentae  are  united  in  a  single  mas  1  in 
winch  the  circulation  of  the  two  fceti  is  sometimes  distinct,  some- 
times common.  There  is  only  a  common  chorion,  but  the  two 
amnions  constitutes  distinct  cavity  for  each  foetus.  The  septum  is 
formed  by  the  adhesion  of  the  two  amnions  (Fig.  405). 


Fig.  405. — Distinct  sacs:  amniotic  septum. 

3.  Fusion. — The  placenta  is  common,  as  well  as  the  circulation. 
The  two  fceti  are  situated  in  a  single  cavity  and  float  in  the  same 
liquid;  there  is  only  one  chorion  and  one  amnion  (Fig.  406). 

Symptoms. — Interrogation. — Exaggeration  of  the  malaise  of  preg- 
nancy ( ?).  Sensation  of  the  foetal  movements  over  a  great  extent  of 
the  abdomen,  or  in  two  regions  clearly  separated  from  each  other. 


354  Multiple  Pregnancy. 

Inspection. — Exaggeration  of  the  size  of  the  abdomen  in  relation 
to  the  epoch  of  the  pregnancy,  as  in  hydramnios.  Subpubic  oedema, 
with  or  without  cedema  of  the  lower  limbs,  as  in  hydramnios. 

Palpation. — Continued  tension  of  the  uterine  wall,  rendering  ex- 
ploration of  the  uterine  contents  difficult.  Frequent  depression  of 
the  fundus  of  the  uterus,  and  vertically  on  the  median  line  of  the 
anterior  face  of  the  uterus  (Herrgott).  Palpation  permits  the  dis- 
covery of  two  fceti,  the  different  parts  of  which  are  recognized,  as  in 
simple  pregnancy.  Sometimes  the  four  fcetal  poles  are  easily  per- 
ceived ;  sometimes  three,  or  only  two,  are  clearly  perceptible,  ac- 
cording to  the  different  attitudes  of  the  fcetus. 

Auscultation. — The  rule,  if  both  fceti  are  living,  is,  that  there 
exist  two  foci  of  auscultation  in  relation  with  the  situation  occupied 
by  the  cardiac  zone  of  each  child ;  exceptionally  there  exists  only 
one  focus,  the  situation  of  one  fcetus  interrupting  the  perception  of 
its  heart  sounds. 


Fig.  406. — Fusion  of  the  two  sacs. 

Digital  examination.  —  When  there  is  a  vertex  presentation,  the 
ballottement  is  less  clear  and  perceived  with  greater  difficulty  than 
in  a  simple  pregnancy.  In  hydramnios  the  opposite  is  the  case. 
Complete  or  incomplete  effacement  of  the  cervix  before  accouche- 
ment is  frequent,  as  in  hydramnios,  in  any  over-distention  of  the 
uterus  during  pregnancy. 

The  diagnosis  should  especially  differentiate  from  hydramnios. 
The  distinctive  signs  are  the  palpation  and  auscultation  of  a  single 
foetus,  the  extended  fluctuation  in  hydramnios  and  the  perception 
of  numerous  small  fcetal  parts  in  twin  pregnancy. 

B.  Accouchement. 

a.  Eutocia. — The  first  accouchement  occurs  as  in  a  simple  preg- 
nany.  After  the  expulsion  of  the  first  child  it  is  necessary  to  place 
two  ligatures  on  the  cord,  one  fcetal,  the  other  maternal,  to  avoid  the 


Multiple  "Pregnancy.  :'>',.'> 

hemorrhage  from  the  maternal  end,  as  it  would  l>e  fatal  to  the 

seeond  child  in  case  of  a  common  circulation. 

The  time  which  separates  the  first  accouchement  from  the  seeond 
is  usually  a  quarter  of  an  hour;  it  may  be  shorter  or  Longer,  and 
lasts  for  eight  or  ten  hours  and  even  more.  In  fact,  when,  the  two 
fceti  being  completely  distinct,  one  foetus  has  been  expelled  before 
term  and  with  its  appendages,  the  cervix  may  close  and  pregnancy 
continue  its  course  to  normal  term,  ;it  which  moment  the  second 
foetus  remaining  intact  will  be  expelled  as  in  the  case  of  simple 
pregnancy. 

The  second  accouchement  is  reduced  to  the  period  of  expulsion, 
for  the  dilatation  being  complete  after  the  passage  of  the  first  child 
the  second  has  only  to  traverse  the  open  genital  passage.  The 
second  foetus  will  be  preceded  or  not  by  a  bag  of  waters,  according 
as  the  amniotic  cavity  was  single  or  double.  This  second  accouche- 
ment is  generally  rapid. 

The  delivery  of  the  appendages  takes  place  after  the  expulsion  of 
the  two  fceti,  the  two  placentae,  united  or  separate,  being  expelled 
as  a  whole,  as  after  simple  accouchement.  Exceptionally,  the 
appendages  of  the  first  child  may  be  expelled  before  the  second 
accouchement.  This  delivery  should  be  favored  only  in  case  the 
placenta  is  engaged  in  the  vagina  or  occupies  the  passage  which  the 
second  foetus  must  follow. 

b.  Dystocia. — The  dystocia  may  be  of  maternal  or  fcetal  origin. 

Maternal  dystocia.  —  The  various  maternal  complications  (ec- 
lampsia, hemorrhage,  rigidity  of  the  cervix,  etc.)  will  be  treated  as 
in  the  case  of  a  simple  accouchement. 

After  the  first  accouchement,  if  the  second  delays,  at  the  end  of 
what  time  is  it  necessary  to  interfere  ?  In  case  of  pressing  danger 
for  the  mother  (haemorrhage)  or  for  the  child  (retardation  of  the 
cardiac  pulsations)  the  accouchement  should  be  terminated  at  once. 
In  the  contrary  case,  if  the  presentation  is  that  of  the  vertex  or  of 
the  breech,  and  if  the  cervix  does  not  close,  an  hour's  time  should 
be  allowed  nature  to  act  spontaneously,  but  if  after  an  hour,  delivery 
does  not  take  place  it  is  necessary  to  interfere  and  extract  the  child, 
for  a  longer  delay  offers  no  advantage  and  may  be  prejudicial  for 
the  child. 

Exception :  However,  we  are  authorized  not  to  interfere,  even 
after  an  hour,  when  the  three   following  conditions  are  united: 

1.  First  ovum  completely  expelled  (that  is  with  its  appendages). 

2.  Expulsion  of  the  first  ovum  before  term.  8.  Mother  in  good 
condition.  In  these  conditons,  in  fact,  the  pregnancy  is  capable  of 
continuing  to  normal  term  and  of  permitting  the  ulterior  develop- 
ment of  the  second  fcetus  without  danger  to  the  mother. 


356 


Multiple  Pregnancy. 


Foetal  dystocia. — This  dystocia  will  vary  with  the  relative  situation 
occupied  by  the  two  fceti. 

1.  Foeti  in  9  9.  —  The  two  heads  may  have  a  tendency  to  engage 
simultaneously  at  the  superior  strait.  The  head  least  engaged 
should  be  pushed  back  to  permit  the  descent  of  the  other. 

2.  Foeti  in  6  6. — The  difficulties  arise  in  extraction,  on  account  of 
the  number  of  feet  the  hand  may  meet.  Only  one  foot  should  be 
drawn  on. 

3.  Foeti  in  6  9  or  in  9  6. — a.  If  the  first  foetus  presents  by  the  vertex 
it  is  seldom  that  the  accouchement  presents  any  difficulty. 


Fig.  407. —  Cephalic  locking  (Budin) 


b.  "When  the  first  foetus  presents  by  the  breech,  difficulties  arise 
at  the  moment  of  the  passage  of  the  head.  This  cephalic  extremity 
is  arrested  by  the  head  of  the  second  (Fig.  407).  The  indications 
are,  to  attempt  successively  :  1.  To  push  up  the  head  of  the  second 
fcetus  to  permit  the  extraction  of  the  first.  2.  To  apply  the  forceps 
on  the  head  of  the  second  fcetus  ( ?).  3.  Craniotomy  on  the  head  of 
the  second  foetus,  only  in  case  it  is  supposed  to  be  dead.  4.  If  the 
second  foetus  is  living,  as  the  existence  of  the  first  is  very  much 


Multiple  Pregna/ney. 


857 


compromised  by  the  situation  in  which  it  will  remain  Borne  time, 
to  resort  to  craniotomy  or  to  d<  capitation  of  the  firsl  child  in  order 
to  allow  the  extraction  of  the  second  child  alive. 

4.  Fceti  a/ntero-ppBterior. — Same  difficulties  possible  ae  in  the  first 
case,  fu'ti  in  9  9. 

5.  /•'"/;  in  T. —  The  only  difficulty  will  be  with  regard  to  the 
second  child  which  may  present  hy  the  abdomen  or  by  the  tin  rax. 
Version  by  internal  manoeuvres  after  the  birth  of  the  first  child. 

G.  Firtl  in  jj  iiircrlcd. — Three  cases  may  be  observed  : 
1.  The  first  foetus  presents  transversely  and  completely  obstructs 
the  superior  strait.  The  first  child  should  be  extracted  by  version, 
or,  if  necessary,  by  embryotomy.  If  the  second  foetus  is  easily 
accessible  its  extraction  should  first  be  attempted  before  resorting 
to  embryotomy. 

Then  the  second  child,  being  insinuated  between  the  first  child 
and  the  uterus,  thus  descends  to  present,  first,  either  by  the  vertex 
(second  case)  or  by  the  breech  (third  case). 


Fig.  408.— Locking  of  the  fceti  (Jacquemier). 

2.  By  the  vertex. — The  shoulder  of  the  child  which  presents  by  the 
vertex  may  be  arrested  by  the  neck  of  the  foetus  placed  transversely 
(Fig.  408).  The  indications  are,  to  attempt  successively :  1.  To 
liberate  the  shoulders,  if  the  introduction  of  the  hand  is  possible. 

2.  To  extract  with  the  forceps  the  child  which  presents  by  the  vertex. 

3.  To  perform  either  craniotomy  of  the  head  winch  presents,  or 
decapitation  of  the  other  foetus,  according  to  the  relative  facility  of 
the  operations,  and  according  to  the  chances  of  life  pertaining  to 
one  or  the  other  child.  To  extract  by  internal  version  the  child 
remaining  in  the  uterus. 

3.  By  the  breech. — Possible  locking  of  the  head  of  the  child  en- 
gaged with  the  neck  of  the  foetus  (Fig.  409).    The  indications  are,  to 


358 


Multiple  Pregnancy. 


attempt  successively  :  1.  To  liberate  the  engaged  head  with  the 
hand.  2.  To  perform  decapitation  of  one  or  the  other  child,  indif- 
ferently, unless  the  foetus  remaining  in  the  uterus  is  not  dead.  Then 
decapitation  of  the  foetus  half  expelled  will  be  preferred,  on  account 
of  the  greater  facility  of  the  operation  and  the  small  chance  of  ex- 
tracting the  child  living.  The  child  placed  transversely  is  brought 
down  by  internal  version. 

7.  Fa'ti  in  hammock.  —  Spontaneous  delivery  is  impossible.     The 
two  children  will  be  successively  extracted  by  internal  version. 


Fin.  409. — Locking  of  the  fceti  (Penard). 

II.  Three  to  five  children  at  a  birth — These  pregnancies 
are  extremely  rare.  Their  diagnosis  is  possible  before  labor  (Pinard). 
The  knowledge  of  the  difficulties  that  have  drawn  our  attention  to 
double  accouchements  permits  us  to  surmount  the  causes  of  dystocia 
that  may  be  met  in  these  exceptional  cases. 


Premature  Expulsion.  359 


CHAPTER  XXIV. 


PREMATURE    EXPULSION. 

Premature  expulsion  is  that  which  takes  place  before  the  normal 
term  of  the  pregnancy,  that  is,  before  nine  months,  counting  from 
the  moment  of  conception.  During  the  first  six  months  (180  days) 
it  is  designated  as  abortion,  and  during  the  last  three  as  premature 
accouchement.  According  to  the  epoch  at  which  it  takes  place 
abortion  is  distinguished  as  embryotic  (first  three  months)  and  fatal 
(second  three  months). 

Pathogeny  and  cetiology. — In  the  pathogeny  of  premature  expulsion 
three  principal  factors  are  admitted : 

The  ovuni  (appendages  and  foetus)  (pathological  state  or  death). 

The  uterus  (contractions  of  the  uterine  muscular  structure). 

Any  foreign  body  occupying  the  ovulo-uterine  space  (haemor- 
rhages, sounds,  etc.). 

But  whatever  the  pathogenetic  factor  that  acts  primarily,  and 
whatever  may  be  the  origin  of  the  accident,  it  is  upon  uterine  con- 
traction that  the  principal  role  devolves,  that  of  the  efficient  cause. 
Aside  from  this  single  efficient  cause  there  are  numerous  determin- 
ing causes  that  we  shall  study  as  follows : 

I.  Non-traumatic  causes. 

A.  Father. 

1.  Extra-genital  causes. — Any  cause  which  is  capable  of  producing 
debility  or  enfeeblement  of  the  organism  may  interupt  the  ulterior 
development  of  the  ovum.  Such  are :  advanced  age,  precocious 
senility,  abuse  of  sexual  relations,  various  diseases  (tuberculosis, 
albuminuria,  diabetes,  and  syphilis  especially),  various  poisons,  as 
lead,  tobacco,  alcohol  and  sulphide  of  carbon. 

2.  Genital  causes.  —  These  are  essentially  local,  such  as  orchitis, 
prostatitis,  urethritis,  and  strictures. 

B.  Mother. 

1.  Extra-genital  causes. — Any  cause  of  organic  debility,  whatever 
its  source,  may  act  as  an  interruption  to  the  development  of  the 
foetus. 

Heredity. — In  some  families  the  women  seem  more  predisposed  to 
abortion  than  in  others.  A  first  abortion  exposes  to  repetition, 
especially  at  a  corresponding  epoch  of  subsequent  pregnancies. 


3G0  Premature  Expulsion. 

Obesity  is  a  cause  of  sterility  and  also  of  abortion.  Very  fat 
animals  are  bad  breeders. 

Age. — At  the  two  extremes  of  genital  life  the  woman  seems  more 
often  subject  to  abortion. 

Hygiene,  alimentation. — A  bad  hygiene  and  an  insufficient  alimen- 
tation expose  to  interruption  of  pregnancy. 

Altitude. — Saucerotte  states  that  women  who  live  in  the  mountains 
of  the  Vosges  are  more  exposed  to  abortion  than  those  who  live  on 
the  plains  (?). 

Medicaments. — Certain  drugs,  such  as  ergot,  rue,  sabina,  sulphate 
of  quinine,  salicilate  of  soda,  etc.,  are  reputed  to  have  abortifacient 
properties. 

Chronic  diseases. — The  majority  of  chronic  diseases  (tuberculosis, 
albuminuria,  diabetes,  cancer)  predispose  to  abortion  by  debilita- 
tion of  the  organism.  Syphilis  should  be  especially  mentioned  on 
account  of  its  importance.  Poisoning  by  lead,  tobacco,  alcohol  and 
sulphide  of  carbon  are  also  causes. 

Acute  diseases. — Any  acute  disease,  which  acts  violently  on  the 
organism,  either  by  elevation  of  temperature  or  by  disordered 
function,  is  capable  of  causing  premature  expulsion  of  the  ovum. 
I  only  recall  the  principal  ones,  cholera,  typhoid  fever,  eruptive 
fevers,  intermittent  fevers,  cardiopaths,  incoercible  vomiting,  etc. 

Epidemic  abortion. — Among  animals,  especially  among  cows,  there 
sometimes  exists  an  epidemic  of  abortions  which  attacks  all  the 
females  of  one  stable  or  of  one  locality.  Nocard  has  shown  that 
this  is  due  to  a  microbe  acting  on  the  genital  organs  and  trans- 
mitted from  one  animal  to  another.  Antisepsis  arrests  the  epi- 
demic. Hervieux  has  attempted  to  demonstrate  that  pregnant 
females  brought  in  contact  with  puerperal  septicaemia  are  also  pre- 
disposed to  abortion,  but  the  proof  is  not  positive. 

2.  Genital  causes. — These  may  be  periuterine,  uterine,  or  intra- 
uterine. 

Periuterine.  —  Any  obstacle  to  the  development  of  the  uterus 
^abdominal  tumors,  especially  ovarian  cysts,  adhesions  left  by  a 
previous  pelvic  peritonitis)  may  cause  premature  expulsion  of  the 
ovum. 

Uterine. — The  same  is  true  of  the  majority  of  uterine  diseases 
congestion,  metritis  and  endometritis,  deviations,  fibroids,  cancer). 
At  an  epoch  corresponding  to  each  menstruation  there  occurs  a 
congestive  impulse,  which  predisposes  to  abortion.  Any  genital 
excitation  may,  by  inducing  congestion  or  uterine  contractions, 
favor  premature  expulsion. 

Intro-uterine. — We  shall  take  into  question  here  the  effusions  of 
blo^)d,  which  may  occur  between  the  ovum  and  the  uterine  wall, 
that  is  to  say,  utero-ovuline  haemorrhages.     These  haemorrhages, 


Prematun    K /pulsion. 


:;.;i 


which  have  their  source  in  the  uterus,  are,  exceptionally,  produced  at 
the  level  of  the  membranes  (ut<  ro-membranoua  hemorrhages),  but 
almost  always  in  a  corresponding  zone  of  the  placenta  (utero- 
placental hemorrhages).  According  as  the  blood  remains  im- 
prisoned in  the  uterine  cavity,  or  flows  out  without  remaining  in  the 
uterus,  or  as  these  two  conditions  are  united,  the  hemorrhage  is 
called  internal  (Fig.  412),  external  (Fig.  413)  or  mixed  (Fig.  414). 
The  result  of  these  hemorrhages  varies  according  to  the  abundance 
and  the  extent  of  the  placental  detatchment,  hut  they  usually  cause 
premature  expulsion  of  the  ovum. 


Fig.  412. — Internal 
haemorrhage. 


Fig.  413. — External 
haemorrhage. 


Fig.  414. — Mixed 
haemorrhage. 


C.  Ovum. 

1.  Appendages. 

Placenta. — Degenerations  of  the  placenta,  when  they  are  marked 
cause  the  death  of  the  foetus  and  abortion.  Vicious  insertion  some- 
times terminates  in  the  same  result. 

Membranes. — Expulsion  of  the  ovum  usually  follows  rupture  of  tie 
membranes  after  a  brief  delay. 

Liquor  amnii. — Hydramnios,  when  it  is  very  marked,  and  es- 
pecially the  acute  form,  is  a  possible  cause  of  abortion  and  of  pre- 
mature accouchement. 

2.  Foetus, — Any  cause  that  produces  the  death  of  the  fcetus  is  also 
a  cause  of  its  premature  expulsion.  Monstrosities  act  in  the  same 
direction.  With  regard  to  multiple  pregnancy,  it  often  produces, 
by  excess  of  uterine  distention,  expulsion  before  term,  but  premature 
accouchement  rather  than  abortion. 

II.  Traumatic  causes 
A.  Mother. 

1.  Extra-uterine  causes.  —  Any  traumatism  on  a  region  distant 
from  the  genital  sphere  may  Le  the  cause  of  premature  expulsion  of 


362  Premature  Eipulsion. 

the  ovum.  I  have  already  spoken  of  surgical  operations  and  of 
their  influence  on  the  progress  of  pregnancy. 

2.  Genital  causes. — Periuterine.  —  Any  traumatism  affecting  the 
abdominal  wall  is  capable  of  causing  premature  expulsion  of  the 
ovum.  A  prolonged  compression  of  the  abdomen  may  produce  the 
same  result. 

Uterine. — Any  traumatism  acting  on  the  cervix,  operation,  cauteri- 
zation, digital  exploration,  vaginal  injection  with  too  much  force  or 
sexual  excess,  may  be  abortive. 

Intro-uterine. — Any  foreign  body  penetrating  between  the  uterus 
and  the  membranes,  accidentally  or  voluntarily  (therapeutically  or 
criminally),  causes  detachment  to  a  certain  extent  and  usually 
provokes  premature  expulsion. 

B.  Ovum. 

1.  Appendages. — The  same  traumatism  which  detaches  the  mem- 
branes may  rupture  them.  Its  abortive  action  in  such  cases  is  still 
more  certain. 

2.  Foetus. — The  action  is  the  same  if  the  instrument  which  has 
perforated  the  membranes  attacks  and  wounds  the  foetus. 

Such  are  the  multiple  causes  and  in  spite  of  their  number  it  often 
happens  that  the  physician  finds  difficulty  in  seeking  the  origin  of 
the  premature  expulsion. 

Pathologicel  anatomy  and  symptomatology. 

a.  First  three  months. — Embryonal  abortion  (Fig.  415) .  —  I  shall 
take  as  a  type  for  description  the  abortion  which  occurs  at  the 
middle  or  at  the  end  of  the  secondmonth  reserving  some  final 
words  for  that  of  the  first  and  third  month. 


Fig.  415. — Ovum  expelled  as  a  whole  (no  effacement)  ABC. 

The  woman  has  had  a  menstrual  suppression  and  has  perceived 
various  sympathetic  phemomena;  she  suspects  pregnancy.  Then 
follows  a  genital  haemorrhage,  simulating  a  simple  return  of  the 
menses,  or  colic  caused  by  painful  uterine  contractions.  Whatever 
may  be  the  beginning,  pain  or  flow  of  blood,  these  two  symptoms 
are  very  soon  united  and  continue  together.  Local  examination 
shows  a  certain  softening  of  the  cervix,  and  an  increase  in  the  size 


Premature  Expulsion. 


303 


of  the  body  of  the  uterus  accompanied  by  ti  nsion  of  the  contiguous 
tissues.  The  external  orifice  of  the  cervix  is  sometimes  closed  and 
sometimes  open  and  occupied  by  the  ovum.  The  ovum  is  generally 
expelled  as  a  whole,  and  in  a  single  stage,  into  the  interior  of  the 
vagina.  It  traverses  thecervix  by  opening  successively  the  isthmus, 
the  cervical  canal  and  the  external  orifice,  but  without  producing, 
properly  Bpeaking,  effacement. 


? 


Fig.  41S. — Ovum  expelled,  in  three  stages  (no  effacement).  A  B  C,  expulsion  of 
the  embryo ;  D  E  F,  expulsion  of  the  appendages  less  the  decidua :  GUI.  expulsion 
of  the  decidua. 

After  the  expulsion  of  the  ovum,  the  pain  subsides  and  the  hemor- 
rhage diminishes.  During  some  days  there  is  a  sero-sanguinolent 
flow,  becoming  mucous  finally.  In  three  to  four  weeks  the  uterus 
has  regained  its  normal  size. 

During  the  first  mouth  of  pregnancy  the  condition  of  gestation 
is  often  ignored  and  abortion  occurring  at  the  menstrual  period  is 
frequently  mistaken  for  the  monthly  flow,  the  ovum  being  expelled 
unnoticed. 


364  Premature  Expulsion. 

During  the  third  month  the  abortion  resembles  that  of  the  second 
month  with  the  difference  that  the  ovum  being  large  the  pains  and 
hemorrhages  are  more  marked. 

b.  Second  three  months  (Fig.  418). — Here  I  shall  also  take  as  a 
type  abortion  occurring  in  the  middle  of  this  period,  that  is  to  say 
during  the  fifth  month. 

Pregnancy  has  become  quite  probable,  sometimes  even  certain, 
when  one  of  the  three  following  symptoms  occur  to  mark  the  be- 
ginning of  the  abortion : 

A  sudden  loss  of  amniotic  liquid. 

A  genital  haemorrhage. 

Uterine  colic,  with  its  usual  characteristics. 

Pain  and  haemorrhage  soon  appear,  when  they  have  not  been  the 
initial  phenomena  and  continue  with  variable  intensity  until  the 
accident  has  terminated  or  has  been  avoided.  Touch  combined  with 
palpation,  permits  us  to  detect  the  characters  proper  to  the  gravid 
uterus  and  to  follow  the  expulsion  of  the  foetus,  which  usually  occurs 
in  the  following  manner  : 

First  stage. — Expulsion  of  the  foetus. 

Second  stage. —  After  a  variable  time,  expulsion  of  the  ap- 
pendages less  the  decidua. 

Third  stage. — Expulsion  of  the  decidua  as  a  whole  or  in  sections. 

It  sometimes  occurs  that  the  decidua  is  expelled  at  the  same 
time  with  the  appendages,  so  that  the  abortion  is  completed  in  two 
stages.  However,  expulsion  of  the  ovum  in  three  stages  and  the 
non-effacement  of  the  cervix  may  be  considered  as  the  two  char- 
acteristics of  abortion  at  this  period. 

The  duration  of  the  expulsion  is  quite  variable,  it  extends  from 
some  hours  to  several  days.  The  pains  and  the  haemorrhages  cease 
after  the  complete  evacuation  of  the  uterus.  A  lochial  discharge  of 
some  days  occurs  and  in  three  to  four  weeks  the  uterus  has  re- 
turned to  its  normal  size. 

c.  Third  three  months. — Premature  accouchement. — Premature  ac- 
couchement is  an  exact  copy  of  accouchement  at  term,  and,  like  it, 
occurs  in  two  stages :  the  first,  for  the  expulsion  of  the  child,  and  the 
second  for  the  delivery  of  the  appendages.  The  puerperal  state  is 
the  same  in  both  cases  and  of  about  the  same  duration  (Fig.  4'27). 

Anomalies  of  the  delivery  of  the  appendages. — Before  placental  de- 
velopment there  may  be  observed  more  or  less  complete  retention 
n\'  the  ovuline  envelopes  which  are  finally  eliminated  in  sections. 
When  the  placenta  is  distinct  various  conditions  may  occur: 

1.    Sometimes   the   placenta   is   completely  detached  from  the 


Premature  Expulsion. 


;;.;;, 


uterine  wall  and  elimination  takes  place,  after  a  variable  time, 
either  as  a  whole,  or  by  Bection,  with  the  possible  accompaniment 
of  septicemic  accidents. 
•1.  Sometimes  the  placenta  is  partly  adherent  and  partly  detached ; 

the  retention  in  Mich  cases  may  lie  prolonged.  The  detached  part 
becomes  necrotic  and  is  eliminated  in  fragments,  while  the  adherent 
[•art  continues  to  live  as  a  parasite  on  the  uterine  wall,  becoming 
the  source  of  obstinate  hemorrhages  which  necessitate  intervention. 
3.  The  placenta  sometimes  remains  totally  adherent  to  the 
uterus.  After  a  prolonged  retention  without  accidents,  the  placenta 
may  he  expelled  as  a  whole.  In  place  of  this,  its  expulsion  in 
several  fragments  of  variable  volume  may  he  ohserved.  Finally,  in 
some  exceptional  cases,  absorption  of  the  retained  placenta  has  been 
observed. 


Fig.  427. — Ovum  expelled  in  two  stages.     A//  B//,  expulsion  of  the  foetus; 
C//,  expulsion  of  the  appendages  (effacement). 

Complications. — Septicaemia,  localized  (pelvic  peritonitis)  or  gen- 
eralized, is  frequently  observed  as  a  consequence  of  abortion,  es- 
pecially when  there  is  retention  of  a  part  or  of  the  whole  of  the 
appendages. 

Uterine  hemorrhage  may  precede,  accompany  or  follow  the  ex- 
pulsion of  the  ovum.  The  loss  of  blood  is  sometimes  so  grave  that 
it  causes  syncope  and  even  the  death  of  the  woman. 

Tetanus. — This  complication,  although  very  exceptional,  has  been 
observed  a  certain  number  of  times  in  consequence  of  abortion. 

1.  Premonitory  treatment. — A  woman  having  had  a  series  of  preg- 
nancies terminated  by  premature  expulsion,  and  is  again  pregnant, 
what  should  be  done  to  avoid  a  repetition  of  the  accident"?  All 
supposed  causes  of  premature  expulsion  must  be  treated.  In  the 
absence  of  the  various  known  and  clearly  derminable  causes  there 


366  Premature  Expulsion. 

are  pregnancies  in  which  the  interruption  seems  to  be  clue  to  irri- 
tability or  to  congestion  of  the  uterus,  these  two  states  terminating 
in  exaggerated  contractions  of  the  uterine  muscle  and  in  premature 
expulsion  of  the  ovum.  Irritability  is  recognized  by  the  facility 
with  which  painful  contractions  of  the  organs  are  produced  and  will 
be  combatted  by  absolute  repose  in  bed  during  a  variable  time.  The 
use  of  opiates  and  of  viburnum  prunifolium  and  the  absence  of 
sexual  relations  are  also  to  be  recommended.  Uterine  congestion 
is  to  be  treated  by  rest  in  the  horizontal  position,  by  intestinal  lax- 
atives and,  if  the  woman  is  plethoric,  by  repeated  bleedings  of  200 
to  300  grammes. 

2.  Prophylactic  treatment. — If  there  be  a  menace  of  premature 
expulsion,  what  treatment  should  be  instituted  to  prevent  abortion  ? 
For  the  execution  of  this  prophylactic  treatment  absolute  repose  in 
bed  is  necessary.  Either  viburnum  prunifolium  or  opiates  will  be 
administered. 

3.  Curative  treatment. 

a.  Before  expulsion. — The  indications  are  for  intervention  only 
in  case  of  accident.  Haemorrhage  is  the  principal  and  the  most 
frequent  complication.  The  best  treatment  to  oppose  to  this  is  tam- 
ponnement  of  the  vagina.  In  premature  accouchement,  the  haemor- 
rhage being  almost  always  due  to  a  placenta  praevia,  the  treatment 
for  that  condition  is  required.  Ergot  should  never  be  given.  During 
expulsion  of  the  ovum  care  must  be  taken  to  avoid  drawing  on  the 
part  engaged  in  the  cervix,  as  by  this  the  ovum  may  be  ruptured  and 
a  fragment  retained  that  will  be  difficult  to  extract.  During  pre- 
mature accouchement  the  management  is  similar  to  that  of  labor 
at  term. 

b.  After  complete  expulsion. — If  the  case  be  one  of  premature  ac- 
couchement, the  management  will  be  the  same  as  in  retention  of 
the  placenta  in  delivery  at  term.  But  if  the  pregnancy  be  less  ad- 
vanced at  the  time  of  expulsion,  and  if  there  be  a  retention  of  the 
placenta,  or,  before  its  formation,  of  ovuline  membranes,  what 
should  be  the  line  of  conduct?  In  the  absence  of  accidents  (septi: 
caemia  or  haemorrhage)  expectation  with  rigorous  antisepsis  is 
clearly  indicated,  for,  in  the  great  majority  of  cases,  the  expulsion 
of  the  membranes  or  of  the  placenta  takes  place  spontaneously  after 
some  hours  or  some  days.  But  if  accidents  follow,  the  danger  be- 
comes pressing  and  it  becomes  necessary  to  interfere.  Here  the 
<>!>  Metricians  are  divided  into  two  camps,  the  evacuators  and  the 
anti-evacuators  of  the  uterus. 

The  evacuators,  in  cases  of  haemorrhage  or  of  septicaemia,  after 
having  dilated  the  cervical  canal  if  necessary,  draw  the  cervix  down 
with  the  vulsellum  and  remove  the  placenta  and  the  membranes 


Premature   Expulsion.  B67 

retained  in  the  uterus,  by  the  aid  of  the  fingers,  or  the  ovum  forcepe 
(Fig  431),  or  by  the  curette.  The  intervention  is  terminated  by 
intra-uterine  irrigation  and  by  intra-uterine  tamponnement,  if 
necessary. 


Fig.  431. — Ovum  forceps. 

The  anti-evacuator,  dismayed  by  an  intervention  which  they  con- 
sider useless  and  dangerous,  comhat  the  haemorrhage  by  vaginal 
tamponnement  and  the  septicaemia  by  frequent  vaginal  injections. 

Both  these  methods  have  their  advantages  and  their  dis- 
advantages, hut  in  spite  of  the  good  results  given  by  the  latter 
procedure  it  offers  less  security. 

c.  "When  the  uterus  is  completely  evacuated,  regression  occurs  in 
a  normal  manner,  except  in  case  of  complications  analogous  to 
those  following  after  accouchement  at  term  and  which  will  lie 
treated  hy  similar  methods.  The  woman  should  remain  in  bed  the 
same  length  of  time  as  after  delivery  at  term. 


368  Accidents  of  Accouchement. 


CHAPTER  XXV. 


ACCIDENTS   OF   ACCOUCHEMENT. 

Ruptures  and  lacerations  of  the  perineum,  of  the  vagina,  and  of 
the  uterus  have  already  been  discussed  and  we  have  here  only  to 
consider  haemorrhages,  procidence  of  foetal  members  and  of  the 
cord,  subcutaneous  emphysema  and  fractures. 

Haemorrhages.  —  Genital  haemorrhages  that  occur  during  ac- 
couchement may  proceed  from  the  vulva,  from  the  vagina,  from  the 
cervix,  or  from  the  body  of  the  uterus.  They  are  traumatic  or 
spontaneous. 

a.  Vulvar  hemorrhages. — Traumatic  causes :  Any  accidental  or 
operative  traumatism  may  produce  a  haemorrhage  of  variable  im- 
portance, but  usually  slight  unless  a  varicose  vein  has  been  opened. 

Spontaneous  causes :  Rupture  of  a  varix  may  give  rise  to 
abundant  haemorrhage. 

Treatment :  Compression,  forcipressure,  sutures. 

b.  Vaginal  hemorrhages.  —  The  causes  are  analogous  to  those 
producing  vulvar  haemorrhage.  These  haemorrhages  are  quite  ex- 
ceptional before  the  expulsion  of  the  foetus  and  after  accouchement. 
They  often  make  a  part  of  those  of  delivery  of  the  appendages, 
which  will  be  studied  later. 

c.  Cervico-uterine  hemorrhages. — At  the  beginning  of  labor,  and 
especially  among  the  primiparae,  the  opening  of  the  cervix  produces 
a  slight  haemorrhage  from  the  excoriations  of  the  mucosa.  Truly 
serious  haemorrhages  result  from  lacerations  produced  by  the 
passage  of  the  foetus. 

d.  Hemorrhages  from  the  body  of  the  uterus  almost  always  depend 
upon  a  vicious  insertion  of  the  placenta.  A  placenta  normally  in- 
serted may  sometimes  furnish  a  certain  quantity  of  blood  by  its 
detachment.  But  these  haemorrhages  are  in  general  of  too  small 
importance  to  require  special  treatment. 

Procidence  of  foetal  members  and  of  the  cord. 

a.  Procidence  of  the  cord. — The  cord  is  said  to  be  prolapsed  when 
it  is  insinuated  between  the  foetal  part  which  presents  and  the  wall 
of  the  genital  canal. 

Frequency,  one  out  of  one  hundred  accouchements. 


Accidents  of  Accouchement.  869 

Pathogeny  and  (etiology. — In  the  normal  state,  the  part  of  the 
foetus  which  presents  exactly  obstructs  the  genital  canal,  impedes 

the  flow  of  the  liquor  aninii  and  the  procidence  of  the  cord.  Bui 
if  any  cause  obstructs  this  eutocic  adaptation  the  liquor  amnii  and 
the  cord  obeying  gravity  and  the  uterine  contractions  are  drawn 
toward  the  vagina  and  prolapse  of  the  cord  is  thus  constituted.  The 
different  causes  capable  of  producing  this  result  are  the  following: 

1.  Ocum. 

a.  Fo3tU8. 

1.  Small  volume. 

2.  Presentation  other  than  the  vertex. 

3.  Multiple  pregnancy. 

4.  Previous  procidence  of  a  member. 

b.  Appendages. 

1.  Hydramnios. 

2.  Placenta  pra^via. 

3.  Exaggerated  length  of  the  cord. 

4.  Knots  of  the  cord  (?). 

5.  Premature  rupture  of  the  membranes. 

2.  Mother. 

a.  Uterus. 

1.  Absence  of  tonicity  of  the  inferior  segment. 

b.  Pelvis. 

1.  Pelvic  deformities,  or  any  cause  preventing  engage- 
ment of  the  foetal  part. 

3.  Obstetrician. 

1.  Any  intervention  improperly  performed  is  capable  of 
causing  procidence  of  the  cord. 

Symptoms  and  diagnosis. — Two  cases  may  present,  one  where  the 
membranes  are  intact,  the  other  where  the  bag  of  waters  has  broken. 

a.  Intra- ovuline  j)vocidence. — Membranes  intact. — When  the  cervix 
is  not  open,  the  cord  is  difficult  to  perceive  with  the  finger  through 
the  uterine  wall,  but  with  a  living  child  (pulsations  of  the  cord)  and 
very  thin  cervico-uterine  segment,  an  experienced  finger  can  some- 
times recognize  the  presence  of  the  cord.  In  proportion  as  the 
cervix  opens,  the  diagnosis  becomes  more  and  more  easy,  for  the 
membranes  oppose  only  a  slight  obstacle  to  digital  exploration. 

b.  Membranes  ruptured. — Extira-ovuline  procidence. — First  degree, 
infra-uterine.  The  loop  of  the  cord  does  not  pass  the  external 
orifice.  Second  degree,  intra-vaginal.  The  loop  of  the  cord  lies  in 
the  vagina,  without  opening  the  vulvar  orifice.  Third  degree,  intra- 
vulvar.  The  funicular  loop  projects  through  the  vulva.  Besides 
the  fcetal  part  that  presents  the  exploring  finger  meets  the  cord 


370 


Accidents  of  Accouche  mo  it. 


which  is  recognized  by  its  form  and  its  consistency  and,  in  cases 
where  the  child  is  living,  by  the  pulsations  that  are  felt  by  pressing 
it  between  the  finger  and  a  resisting  plane. 

Prognosis. — Any  arrest  of  the  funicular  circulation  is  the  cause 
of  prompt  death  of  the  foetus,  which  succumbs  to  asphyxia.  Thus 
the  procidence  which  exposes  to  compression  is  very  dangerous  for 
the  foetus;  however,  Depaul's  estimation  of  seventy-five  per  one 
hundred  of  mortality  appears  somewhat  exaggerated. 
The  prognosis  also  depends  : 
Upon  the  degree  of  the  prolapse — the  more  pronounced  it  becomes, 

the  more  the  foetus  is  exposed : 
Upon  the  presentation — the  danger  of  compression  being  greater 

in  vertex  presentations ; 
Upon  the  epoch  of   labor — the   more   advanced   the  labor,  the 

easier  intervention  becomes; 
Upon  the  state  of  the  membranes — with  an  intact  bag  of  waters, 
it  is  rare  to  see  procidence  of  the  cord  become  fatal  to  the 
child ; 
Upon  the  intervention. 


Fig.  432. — Reduction  of  the  cord  by  the  genu- pectoral  position  (Playfair). 

Treatment. — a.   Three  methods  of  intervention. 

1.  Reduction  of  the  cord. — By  the  position  of  the  woman.  The 
woman  being  placed  in  the  genu-pectoral  position  (Fig.  432),  the 
action  of  gravity  is  -ometimes  sufficient  to  reduce  the  cord. 

By  the  use  of  the  hand.  The  cord  being  seized  by  the  extrem- 
ities of  the  fingers  (Fig.  433)  is  returned  to  the  uterus  and,  at  need, 
hooked  over  a  limb  to  avoid  a  new  prolapse.  For  this  purpose 
Mauriceau  applies  a  sponge  in  the  space  through  which  the  cord 
descends. 

By  the  use  of  an  instrument  (Figs.  434  to  43S).  In  one  case  I 
used  a  simple  long  forceps  to  grasp  the  cord  and  to  return  it  to  the 
uterine  cavity  (Fig.  439). 


Accidents  oj  Acc&ueliement. 


371 


Fig.  433. — Reduction  of  the  cord  by  the  use  of  the  hand. 


FIG.  434.— Lyre-shaped  instrument  for  seizing  the  cord  and  liberating 
it  after  reduction. 


372 


Accidents  of  Accouchement. 


Fig.  435. — Double  hook  with  mobile  branches,  permitting  the  cord 
to  be  seized  and  abandoned  after  reduction. 


Fig.  436. — Grasping  hook  of  whalebone,  composed  of  two  handles 
with  parallel  movement. 


Accidents  of  Accouchement. 


378 


1 


Fig.  437. — Ordinary  sound  with  stylet. 


Fig.  438. — Small  fork  of  metal  or  wood  made  on  the  spot,  if  necessary. 


374 


Accidents  of  Accouchement. 


2.  Podalic  version  has  been  advised;  either  by  mixed  or  by 
external  manoeuvres  before  complete  dilatation,  hoping  that  this 
will  reduce  the  prolapse,  or  in  case  of  not  reduction  that  the  prog- 
nosis will  become  less  grave  with  a  presentation  of  the  breech;  or 
by  internal  manoeuvres,  when  dilatation  is  complete,  to  terminate 
accouchement. 

3.  Forceps. — The  application  of  this  instrument  with  complete 
dilatation  is  also  advised. 


Fig.  439. — Simple  long  forceps. 

b.  Clinical  use  of  these  different  methods. — If  the  cormic  ovoid 
presents  (breech,  thorax,  abdomen),  the  management  during  the 
period  of  dilatation  will  be  the  same  as  if  the  funicular  procidence 
did  not  exist,  for  attempts  at  reduction  are  almost  useless,  as  the 
cord  again  prolapses  and  besides  the  danger  is  relatively  small. 
After  complete  dilatation,  in  breech  presentation,  the  pulsations 
must  be  watched  and  extraction  made  if  danger  occurs. 

If  there  be  a  presentation  cf  the  cephalic  ovoid  two  cases  may 
exist : 

If  the  dilatation  is  complete,  the  accouchement  must  be  promptly 
terminated  by  version  or  by  the  forceps. 

If  the  dilatation  is  incomplete,  reduction  of  the  cord  should  be 
attempted  by  the  use  of  the  methods  already  described.  If  these 
procedures  fail,  and  if  the  foetus  is  in  danger,  pelvic  version,  by  ex- 


Accidents  of  Accouchement. 


M:> 


ternal  or  by  mixed  manoeuvres,  should  be  essayed,  with  or  without 
anaesthesia.  Finally,  as  soon  .-i-  dilatation  becomes  sufficient,  the 
child  must  be  delivered  promptly. 

c.  Procidence  of  foetal  membranes  (Fig.  110). — Frequency,  one  per 
one  hundred.  The  causes  and  the  pathogeny  are  the  sameae  those 
given  for  prolapse  of  the  cord.  There  exist  three  degrees  in  the 
procidence  of  the  fatal  members. 

First  degree — hand,  foot. 

Second  degree — forearm,  leg. 

Third  degree — arm,  thigh. 

The  third  degree  is  very  rare  and  can  only  exist  as  a  consequence 
of  tractions  exerted  by  the  accoucheur. 


Fig.  440. — Procidence  of  the  left  superior  member. 

Treatment. — 

Membranes  intact. — Simple  expectation. 

Membranes  ruptured.— When  the  dilatation  is  sufficient  to  permit 
access,  attempt  may  be  made  to  push  up  the  prolapsed  member  with 
the  extremities  of  the  fingers.  If  reduction  is  impossible,  complete 
dilatation  is  awaited  and  if  expulsion  is  still  prevented  recourse  is 
had.  according  to  the  case,  to  version  or  to  the  forceps.  In  vertex 
presentation,  the  forceps  will  be  slipped  between  the  head  and  the 
prolapsed  member  and  extraction  performed  as  if  the  procidence 
did  not  exist. 


376  Accidents  of  the  Delivery  of  the  Appendages. 

Subcutaneous  emphysema  and  fractures. 

Under  the  influence  of  the  excessive  exertions  made  by  the  woman 
during  the  period  of  expulsion  there  have  been  noted,  as  patho- 
logical curiosities,  fractures  of  the  sternum  and  subcutaneous 
emphysema.  Usually  the  emphysema  is  not  grave,  but  it  may 
however,  cause  the  death  of  the  patient. 


CHAPTER  XXVI. 


ACCIDENTS   OF   THE   DELIVERY  OF   THE 
APPENDAGES. 

The  accidents  which  may  complicate  the  delivery  of  the  ap- 
pendages are  usually  divided  into  general  and  local. 

The  general  accidents  relate  to  those  affections  which  attack  the 
organism  in  general  at  this  period,  such  as,  convulsions,  syncope, 
asphyxia,  etc.  The  only  indication  for  their  treatment  is  to  termi- 
nate delivery  as  promptly  as  possible. 

Aside  from  these  general  accidents,  which  we  cannot  study  here 
in  detail,  there  are  numerous  local  complications  that  become  of 
first  importance  in  obstetrics. 

These  local  accidents  that  occur  at  the  moment  of  delivery  of  the 
appendages  may  be  grouped  as  follows  : 

I.  Retention  of  the  appendages  of  the  ovum. 
II.  Haemorrhages. 

III.  Treatment. 

I.  Retention  of  the  appendages  of  the  ovum. 

Divisions,  definitions. — Eetention  may  be  : 

1.  Total:  that  is,  of  all  the  appendages. 

2.  Partial :  of  a  part  of  the  placenta ;  of  the  membranes  as  a 
whole ;  of  a  part  of  the  membranes. 

Eetention  of  the  membranes  seems  at  first  difficult  to  define. 
When,  ten  or  twelve  hours  after  accouchement,  the  placenta  and 
the  membranes  are  still  in  the  uterus  the  diagnosis  is  not  difficult 
to  establish,  but  when,  after  the  expulsion  of  the  foetus,  their  de- 
livery delays,  we  find  it  difficult  to  state  precisely  the  exact  moment 
at  which  the  physiological  state  gives  place  to  the  pathological  state, 
that  is,  to  retention. 

This  difficulty,  however,  does  not  apply  to  the  isolated  retention 


Accidents  of  the  Delivery  of  the  Appendages. 


877 


of  th«'  nu'inlinuK's,  which  exists  whenever,  after  the  expulsion  of  the 
placenta,  part  of  the  whole  of  their  extent  renin  in:-  in  the  uterus,  hut 
only  relates  to  retention  of  the  placenta. 

Now  it  may  be  Baid  that  there  is  a  retention  of  the  placenta  when- 
ever  the  internal  orifice  (uterine  circle,  or  an  orifice  accidentally 
formed  in  the  uterus)  is  sufficiently  dosed  and  rigid  to  prevenl  the 
passage  of  the  placenta  or  that  of  the  hand  thai  seeke  to  extract  it. 
It  is  then  the  internal  orifice,  or  an  accidental  orifice,  which  affords 
the  measure  of  retention  of  the  placenta. 

But  to  what  degree  must  this  orifice  he  closed  to  cause  retention? 
A  mathematical  answer  is  impossible.  The  orifice  must  return  on 
itself  to  a  degree  sufficient  to  constitute  an  obstacle  to  the  passage 
of  the  placenta,  or  to  the  hand  of  the  accoucheur.  It  is  then  the 
placenta  (or  better,  the  hand,  since  it  requires  a  larger  opening) 
which  gives  the  measure,  the  criterion.  I  recognize  that  this  lacks 
precision,  hut  we  must  he  content  with  it  for  want  of  a  better 
standard  (Figs.  441,  442,  443). 


Fig.  441. — No  retention. 


Fig.  442. — Limit. 


Fig.  443.—  Retention. 


Symjitoms  and  diagnosis. — 

1.  Total  retention  of  the  appendages.  — This  total  retention  will  be 
recognized,  when,  in  digital  examination,  a  certain  time  after  ac- 
couchement, one  finds  the  internal  orifice,  or  uterine  circle,  into 
which  passes  the  cord  (unless  it  has  been  separated),  sufficiently 


378  Accidents  of  the  Deliver}!  of  the  Appendages. 

closed  and  rigid  to  prevent  the  passage  of  the  placenta  and  of  the 
hand,  if  it  is  necessary  to  introduce  it. 

Closed  and  rigid  are  the  two  indispensable  conditions  of  retention, 
for  with  a  closed  but  supple  orifice  retention  does  not  exist,  dila- 
tation being  possible  without  difficulty  under  the  influence  of  a 
mechanical  dilatation  (traction  on  the  placenta,  or  the  introduction 
of  the  hand). 

2.  Partial  retention  of  the  appendages. — The  diagnosis  will  be  made 
by  the  examination  of  the  appendages  expelled  and  of  the  woman. 

a.  Retention  of  the  placenta. — Total  retention  of  the  placenta  is  not 
observed  without  simultaneous  retention  of  the  membranes.  We 
have  then  to  note  only  partial  retention  of  the  placenta,  of  a  de- 
tached cotyledon,  or  of  an  accessory  cotyledon.  By  examination  of 
the  appendages  it  will  be  perceived  that  a  part  of  the  placental  sub- 
stance is  wanting  when  on  the  uterine  surface  there  is  a  depressed, 
ragged  region.  However,  with  a  placenta  that  has  been  torn  during 
extraction  'the  diagnosis  may  be  difficult.  The  retention  of  an 
accessory  cotyledon  is  recognized  by  the  existence  of  two  vessels 
running  in  the  same  direction  on  the  membranes  and  suddenly  in- 
terrupted at  the  place  of  rupture  of  the  ovuline  envelopes.  In  case 
of  doubt,  the  introduction  of  the  hand  into  the  uterus  and  the  ex- 
ploration of  the  cavity  permits  us  to  discover  and  to  secure  the 
retained  cotyledon,  which  is  generally  adherent. 

b.  Retention  of  the  membranes. — The  isolated  retention  of  the  mem- 
branes is  easily  discovered  by  examination  of  the  expelled  ap- 
pendages, when  it  is  complete  or  extended;  but  in  cases  where  it  is 
only  constituted  by  a  simple  fragment  the  diagnosis  will  sometimes 
be  doubtful.  This  retention  will  be  suspected  when  in  attempting 
to  reconstruct  the  membranes  in  the  position  that  they  occupy  in 
the  uterus  this  cannot  be  completely  arrived  at.  In  examination 
of  the  patient  the  fingers  will  seek  a  floating  membrane,  the 
presence  of  which  will  leave  no  doubt  as  to  the  diagnosis.  Retention 
may  also  exist  without  the  membranes  being  accessible,  when,  for 
example,  they  are  completely  enclosed  in  the  uterus. 

Progress  and  complications.  —  Retention  of  the  membranes  pro- 
duces no  immediate  accident,  but  may  be,  during  post-partum,  the 
cause  of  haemorrhages,  of  septicaemia,  or  of  after-pains. 

Partial  or  total  retention  of  the  placenta  sometimes  becomes  the 
source  of  the  same  accidents,  but  with  a  much  greater  degree  of 
frequency  and  of  gravity.  In  the  absence  of  complications  this 
retention  may  last  a  variable  time,  from  several  hours  to  several 
days.  The  placenta  is  then  expelled  by  a  new  labor,  as  a  whole,  or 
in  successive  fragments. 

Prognosis. — The  prognosis  of  isolated  retention  of  the  membranes 
is  generally  benign,  on  condition  that  a  rigorous  antisepsis  shall  be 


Accidents  of  the  Delivery  of  the  Appendages.  37'.» 

observed  daring  post-partuin.  Spontaneous  expulsion  is  the  rule. 
That  of  placental  retention  is  more  serious  lor  the  patient  is  expi 
to  septicaemia  and  sometimes  to  grave  haemorrhage.  Thus  we  -hall 
apropos  of  the  treatment,  thai  it  is  nec<  ssary  to  interfere  in 
retention  of  the  placenta,  while  expectation  is  the  best  method  for 
that  of  the  membranes. 

/Etiology. — 

1.  Uterine  inertia,  consecutive  to  accouchement,  prevents  the 
detachment  of  the  placenta  and  its  expulsion.  Uterine  inertia  is 
especially  a  cause  of  dangerous  haemorrhage  and  will  be  Btudied  at 

greater  length  with  this  accident. 

2.  Uteri ik'  spasm. — Spasm  of  the  external  orifice  has  been  wrongly 
admitted  ;  that  of  the  internal  orifice  (uterine  circle),  or  of  an  orifice 
of  new  formation,  placed  above  the  preceeding,  has  alone  been 
proven. 

(a).  Spasm  of  the  internal  orifice. — When  the  placenta  is  completely 
above  the  internal  orifice  we  designate  the  condition  as  encystment, 
when  it  is  more  or  less  engaged  in  this  orifice,  incarceration. 

1.  Encystment  may  exist: 

With  a  total  spasm  of  the  uterus  (Fig.  444). 

With  a  spasm  of  the  internal  orifice  alone  (Fig.  445). 

With  an  irregular  spasm  of  the  body  of  the  uterus  (Fig.  446  . 


Fig.  444.— Total  Fig.  445.— Spa^m  of  the  Fig.  446.— Irregular 

spasm.  internal  orifice.  spasm. 

2.  Incarceration  may  be  : 

Pronounced  (Fig.  447). 

Median  (Fig.  448  . 

Slight  (Fig.  449). 

(b).  Spasm  of  an  orifice  of  neoformation. — In  the  interior  of  the 
uterus,  above  the  internal  orifice  or  uterine  circle,  there  is  formed, 
either  by  paralysis  of  the  uterus  at  the  placental  formation,  or  by 
contraction  of  an  annular  and  limited  region  of  the  uterine  muscle, 


380 


Accidents  of  the  Delivery  of  the  Appendages. 


a  narrowed  portion  dividing  the  cavity  of  the  body  of  the  uterus 
into  two  cells,  the  superior  containing  the  placenta  (Figs.  450  and 


Fig.  447. — Pronounced 
incarceration. 


Fig.  448. — Median 
incarceration. 


Fig.  449. — Slight 
incarceration. 


450  bis).     This  form  of  retention  may  present  the  same  varieties 
of  encystment  and  of  incarceration  as  imprisonment,  that  is  : 


Fig.  450  and  450  bis. — a  b,  orifice  of  neoformation  (spur  of  bifid  uterus); 
cd,  internal  post-partum  orifice  (uterine  circle). 

1.  Encystment  may  exist : 

With  total  spasm  of  the  body  (Fig.  451). 

With  spasm  of  the  neo-orihce  (Fig.  452). 

With  irregular  spasm  (Fig.  453). 

•2.  Incarceration  may  be  : 

Pronounced  (Fig.  454). 

Median  (Fig.  455). 

Slight  (Fig.  450). 

8.  Uterine  rupture,  with  or  without  passage  of  the  placenta  into  the 
peritoneal  cavity  is  a  cause  of  retention. 

4.  Uterine  mat  *<>  filiation. — Bifidity,  obstructing  the  retraction  after 
accouchement,  may  favor  the  retention  of  the  placenta  and  of  the 
membranes. 


Accidents  of  the  Delivery  oj  the  Append* 


381 


Fig.  451. — Total  spasm. 


Fig.  452. — Spasm  of  the 
neo-orifice. 


Fig.  453. — Irregular 
spasm. 


Fig.  454. — Incarceration 
pronounced. 


Fig.  455. — Incarceration 
median. 


Fig.  456. — Incarceration 
>lighi. 


5.  Uterine  tumors.— Any  tumor,  for  example,  a  fibrous  polypus, 
by  obstructing  the  passage  of  the  placenta,  is  capable  of  preventing 
the  expulsion  of  the  appendages  (Fig.  457). 

6.  Tumors  of  the  vulva  and  vagina.— The  same  obstacle  may  some- 
times be  caused  by  a  tumor  of  the  vagina  or  vulva. 

7.  Excess  of  the  volume  of  the  placenta.— This  excess  of  volume 
may  be  due  to  the  size  of  the  placenta  itself,  to  the  addition  of  clots 


382  Accidents  of  the  Delivery  of  the  Appendages. 

adhering  to  its  uterine  surface,  or  to  the  super-tlistention  caused  by 
the  blood  contained  in  the  organ  itself.  The  larger  the  placenta, 
it  will  be  understood,  the  greater  becomes  the  difficulty  in  passing 
the  uterine  circle. 


Fig.  457. — Uterine  fibroma,  obstructing  the  passage  of  the  placenta, 

8.  Adhesions  of  the  placenta. 
Varieties : 

a.  Extent. 

Partial  adhesion. 
Total  adhesion. 

b.  Degree :  three. 

Simple  exaggeration  of  the  physiological  and  normal  state  that 
the  uterus  is  capable  of  overcoming,  in  most  cases,  by  contracting 
with  energy. 

More  intimate  adhesions,  and  such  that  only  the  introduction  of 
the  hand  into  the  uterus  can  separate,  the  connections  uniting  the 
placenta  to  the  uterine  wall. 

Veritable  fusion. — It  is  impossible  to  detach  the  placenta  with  the 
hand,  and  in  post-mortem  it  becomes  necessary  to  use  the  knife  to 
separate  it  from  the  uterus,  so  intimate  is  the  fusion. 

/Etiology. — 

Utero-placental  inflammation. — Leading  to  a  vertible  sclerosis 
that  unites  the  placenta  to  the  uterus  by  fibrous  tissue. 


Accidents  of  the  Delivery  of  the  Appendages. 


383 


Utero-placental  hemorrhage.-— The  clol  which  forms  between  the 
placenta  and  the  uterus  unites  these  organs  by  it.-,  transformation. 

Exaggeration  of  the  physiological  adhesion.  The  supposition  i- 
advanced,  without  explaining  its  mechanism,  that  the  marked  ad- 
hesion which  exists  at  the  fifth  to  the  sixth  month  h;i  -  persisted  to 

term. 

9.  Accessor;)  placenta. — The  existence  of  an  accessory  placenta, 
still  adherent  or  detached  (Fig.  458),  is  a  cause  of  retention.  The 
cotyledon,  thus  isolated,  remains  in  the  uterus  with  a  more  or  less 
considerahle  section  of  the  membranes. 


Fig.  458.— Retention  of  an     Fjg.  459. — Partial  retention 
accessory  cotyledon.  of  the  membranes  of 

adhesions. 


Fig.  460. — Retention  of  the 
membranes  by  a  clot. 


10.  Multiple  pregnancy. — In  multiple  pregnancy  the  placenta,  by 
its  size  or  by  the  existence  of  two  lobes,  predisposes  to  retention. 
"With  this  last  disposition,  the  two  placental  masses  being  separated, 
the  last  to  be  expelled  acts  in  relation  to  the  first  like  an  accessory 
placenta. 

11.  Adhesion  of  the  membranes. — The  adhesion  of  the  membranes 
may  be  of  variable  extent.  Sometimes  the  decidua  alone  is  ad- 
herent, sometimes  the  decidua  and  the  chorion,  finally  the  three 
membranes  may  be  united.  The  causes  are  inflammation  of  the 
membranes,  haemorrhage  of  pregnancy,  and,  with  regard  to  the  de- 
cidua, the  persistence  of  physiological  adhesion.  These  adhesions 
cause  the  retention  of  a  more  or  less  considerable  section  of  the 
membranes  (Fig.  459). 


384  Accidents  of  the  Delivery  of  the  Appendages. 

12.  Clot. — A  blood  clot  enclosed  in  the  membranes  is  sometimes 
retained  at  the  internal  orifice  and  prevents  the  exit  of  the  ovuline 
envelope-  (Fig.  460). 

13.  Untimely  traction  on  the  membranes. — Too  strong  tractions  on 
the  membranes  during  their  exit  may  cause  their  rupture  and  favor 
retention. 

14.  Fragility  of  the  cord. — A  too  fragile  cord  breaks  under  traction 
and,  by  impeding  ulterior  tractions,  thus  facilitates  retention. 

15.  Vicious  insertion  of  the  cord. — The  insertion  of  the  cord  at  the 
edge  of  the  placenta,  or  on  the  membranes,  exposes  to  funicular 
rupture  at  that  point  and  to  the  danger  of  retention. 

16.  Shortness  of  the  cord  may  cause  its  rupture  and  the  same  con- 
ditions as  above. 

17.  Accouchement  in  the  upright  position,  by  causing  rupture  of  the 
cord  at  the  moment  of  expulsion  of  the  child,  exposes  in  the  same 
way  to  ulterior  retention  of  the  appendages. 

18.  Untimely  tractions  on  the  cord  sometimes  terminates  in 
rupture  and  the  unfortunate  results  that  we  have  seen  above. 

II.  Haemorrhages  of  delivery  of  the  appendages. 

Definitions  and  divisions. — In  the  same  way  that  continuance  of 
the  appendages  in  the  uterus  for  a  certain  time  after  accouchement 
is  the  rule,  so  the  flow  of  a  certain  quantity  of  blood  at  the  moment 
of  delivery  of  the  appendages  is  also  normal  and  physiological. 
But  when  does  this  haemorrhage  cease  to  be  physiological  and  when 
does  it  become  pathological  ?  In  the  same  way  that  it  is  impossible 
to  answer  mathematically  as  to  retention,  so  it  is  useless  to  try  to 
give  in  grammes  the  quantity  of  blood  which  should  be  lost  to  con- 
stitute a  pathological  state.  The  best  definition  is  the  following: 
A  haemorrhage  of  delivery  of  the  appendages  becomes  pathological 
when  it  compromises  the  woman's  health. 

This  haemorrhage,  whether  it  precedes,  accompanies  or  follows  the 
expulsion  of  the  appendages,  may  be  internal,  external,  or  mixed. 
These  divisions  have  a  practical  importance,  for  they  show  the 
gravity  of  the  haemorrhage  should  not  be  judged  solely  by  the  quantity 
of  blood  which  escapes  from  the  vulva. 

JEtwlogy. — 1.  Uterine  inertia. — The  detachment  of  the  placenta 
leaves  the  vascular  uterine  surface  bare  and  all  the  vascular  orifices 
gaping.  If  the  uterine  muscular  structure  does  not  contract  at  this 
moment,  to  energetically  close  all  the  vessels,  a  haemorrhage  of  a 
severity  in  proportion  to  the  degree  of  the  uterine  inertia  will  be 
the  consequence. 

'1.  Lacerations  and  ruptures  of  the  uterus. — Any  solution  of  con- 
tinuity affecting  the  cervix  or  the  body  of  the  uterus  may  cause 
haemorrhages  of  variable  gravity.  Rupture  of  the  uterus  may  be 
combined  with  inertia. 


Accidents  of  the  Delivery  of  the  Appendages. 


3ft5 


3.  Uterine  inversion,  of  which  we  may  have  three  degrees,  intra- 
uterine (Fig.  461),  intra- vaginal  (Fig.  462)  and  extra-vulvar  (Fi  . 
168),  produces  a  persistent  bamorrhage,  which  may  become  grave 
by  its  abundance  or  by  its  duration. 


Fin.  461. — Intra  uterine  inversion. 

4.  Lacerations  of  the  vulva  and  of  the  vagina,  by  affecting  important 

vessels,  may  be  the  cause  of  a  more  or  less  serious  haemorrhage. 

5.  Vicious  insertions  of  the  placenta  expose  to  haemorrhages  during 
delivery  of  the  appendages,  for,  after  detachment  of  this  organ,  the 
inferior  segment,  "where  it  was  inserted,  returns  on  itself  less  ea-ily 
than  the  superior,  on  account  of  its  relative  poverty  of  muscular 
fibres. 

G.  Retention  oj  the  appendages. — Every  retention,  partial  or  total, 
of  the  appendages,  may  become  the  source  of  haemorrhage  by  ob- 
structing the  retraction  of  the  uterus. 


III.  Treatment  of  the  accidents  of  delivery  of  the 
appendages. 

1.   The  retention  crisis  alone. — The  retention  ma}r  be  total  or  partial. 

a.  Total  retention.  —  "When  an  hour  after  accouchement  delivery 
of  the  appendages  is  not  yet  accomplished,  we  are  authorized  to 
make  digital  examination  to  ascertain  the  state  of  the  parts  and  of 
the  internal  orifice.  There  are  two  elements  that  must  be  noted 
before  any  intervention : 

The  state  of  the  internal  orifice  (recognized  by  touch). 


386 


Accidents  of  the  Delivery  of  the  Appendages. 


Fig.  462. — Intra-vaginal  inversion. 


Fig.  463. — Extra  vaginal  inversion. 


Accidents  of  the  Delivery  of  the  Appendages.  887 

The  situation  of  the  placenta  (determined  by  touch,  and  presumed 
from  the  distance  of  the  funicular  ligature  from  the  vulva). 

1.  If  the  placenta  is  at  the  level  of  the  internal  orifice,  whatever 
may  be  the  permeability  of  this  opening,  the  indications  are  to 
express,  to  draw,  and  to  wait;  at  the  end  of  a  variable  time  the 
placenta  detaches,  thru  it  becomes  accessible  to  the  finger,  engages 
in  the  cervical  canal  and  will  be  expelled.  Success  is  only  a  question 
of  patience. 

•J.  If  the  placenta  is  not  accessible  at  the  level  of  the  internal 
orifice,  it  may  be  concluded  that  the  detachment  is  not  yet  termi- 
nated. The  management,  then,  varies  according  to  the  permea- 
bility of  the  internal  orifice. 

When  this  orifice  is  supple  and  open,  the  indications  are  to  wait, 
at  the  same  time  essaying  uterine  massage  or  expression,  and,  if 
after  a  certain  time,  the  result  is  nul,  to  act  as  in  the  following  case. 

If  the  internal  orifice  begins  to  close  and  if  it  is  seen  that  longer 
waiting  will  prevent  the  introduction  of  the  hand  it  becomes  neces- 
sary to  proceed  to  artificial  delivery  of  the  appendages. 

h.  Partial  retention.  —  There  may  be  retention  of  a  placental 
fragment,  of  an  accessory  cotyledon  or  of  the  membranes.  When- 
ever the  retention  of  a  placental  fragment  or  cotyledon  is  recognized 
the  hand  should  be  introduced  into  the  uterus  to  effect  its  removal. 
If  the  cervix  presents  an  impassible  barrier,  the  indications  are  to 
wait  and  to  watch  the  woman  attentively,  proceeding  to  curette  the 
uterine  cavity  as  soon  as  a  fetid  flow  or  septicemic  symptoms  pre- 
sent. If  only  a  section  of  the  membranes  is  retained,  simple  ex- 
pectation is  preferable  to  intervention.  But  if  there  is  complete 
retention  of  the  membranes  immediate  intervention  is  preferable. 

•2.  The  hemorrhage  exists  alone  (delivery  of  the  appendages  having 
been  completed). 

To  avoid  repetition  and  discussion  at  length  this  subject  may  be 
presented  in  resume  as  follows : 

a.  Hemorrhages  of  medium  intensity. — Three  successive  conditions 
to  be  determined : 

Uterine  inertia ;  ) 

Vulvar  wound;  V  Causes  of  ha?morrhage. 

Vaginal  or  cervical  wound  ;    ) 

Three  therapeutic  measures  (outside  of  ligatures  and  sutures) : 
Hot  antiseptic  injections,  50°  C. ; 
Ergot ; 

Utero- vaginal  tamponnement. 

h.  Grave  and  fulminant  haemorrhages.  —  A  single  condition  is 
possible : 

Uterine  inertia. 


388  Accidents  of  the  Delivery  of  the  Appendages. 

Three  therapeutic  measures : 

Compression  and  massage  of  the  uterus  through  the  abdominal 

wall. 
Introduction  of  a  hand  into  the  uterus. 
Uterovaginal  tamponnement. 

The  gravity  of  the  haemorrhages  following  delivery  of  the  ap- 
pendages has  aroused  obstetricians  to  the  creation  of  a  series  of 
measures  which  I  consider  inferior  to  those  given  above.  I  simply 
mention  them,  but  advise  that  the  three  already  described  should 
have  the  preference.  Among  these  procedures  are,  intra-uterine 
injection  of  the  perchloride  of  iron,  introduction  into  the  uterus  of  a 
dilatable  rubber  bag,  electricity,  introduction  of  ice  into  the  uterus, 
intra-uterine  injections  of  alcohol,  iodine  or  vinegar,  and  com- 
pression of  the  aorta  through  the  abdominal  wall  or  by  the  hand 
introduced  into  the  uterus. 

3.  The  retention  and  the  hemorrhage  exist  together.  —  The  haemor- 
rhage will  only  cease  with  the  expulsion  of  the  appendages;  to 
deliver  the  appendages  is,  then,  the  first  indication.  If  the  internal 
orifice  is  still  open,  artificial  delivery  will  be  easy,  and,  besides, 
permeability  of  the  internal  orifice  is  the  rule,  for  the  uterine  inertia, 
the  cause  of  the  haemorrhage,  allows  gaping  of  the  cervix. 

If  the  internal  orifice  is  closed  and  does  not  allow  the  passage  of 
the  hand,  a  rubber  bag  will  be  introduced,  which,  by  its  dilatation, 
acts  both  by  opening  the  cervix  and  as  a  plug  to  arrest  haemorrhage. 
At  the  same  time  one  hand  exercises  pressure  on  the  uterus  through 
the  abdominal  wall.  At  the  end  of  one  to  two  hours  the  dilatation 
will  be  sufficient  to  admit  the  hand  and  intra-uterine  intervention 
will  become  possible. 


Accidents  of  Post-Pa rtn m.  389 


CHAPTER  XXVII. 


ACCIDENTS   OF   POST-PARTUM. 

1.  Hamorrhages. —  Post-partum  actually  commences  at  the 
moment  when  delivery  of  the  appendages  terminates,  \>  t  a  haemor- 
rhage, which  occurs  a  half-hour,  an  hour,  or  even  more,  utter  ex- 
pulsion of  the  appendages,  is  still  considered  as  a  haemorrhage  of 
delivery,  responding  to  the  same  causes  and  to  the  same  treatment 
as  those  of  this  period  of  the  puerperal  state.  Among  the  haemor- 
rhages of  post-partum  we  only  rank  those  which  occur  twelve  hours 
after  delivery.  This  is  certainly  an  arbitrary  limit,  but  it  responds 
quite  well  to  the  necessities  of  description.  These  haernorrli; 
are  also  designated  as  secondary,  in  distinction  from  those  occurring 
during  delivery  of  the  appendages,  which  are  primary.  The  post- 
partum lasts  three  months.  We  shall  then  study  here  the  haemor- 
rhages occurring  during  this  period  consecutive  to  the  birth  of  the 
child. 

These  haemorrhages  are  of  a  variable  abundance.  They  are 
sometimes  slight,  almost  physiological,  sometimes  copious  and 
capable  of  endangering  the  life  of  the  patient.  They  may  be  ex- 
ternal or  mixed,  but  the  quantity  of  blood  contained  in  the  uterus 
can  never  be  considerable  as  the  organ  at  this  time  has  returned 
upon  itself. 

^Etiology. — a.  Traumatic  causes. — 

1.  Exploratory  traumatism,  caused  by  the  introduction  of  a  sound 
into  the  uterus. 

2.  Accidental  reopening  of  a  wound  of  the  perinaeum,  of  the 
vagina,  or  of  the  uterus. 

3.  Too  early  resumption  of  sexual  relations. 

4.  Getting  up  too  soon  after  delivery. 

b.  Spontaneous  causes: 

1.  Secondary  inertia  may  be  the  cause  of  a  haemorrnage  even  as 
late  as  two  or  three  days  after  delivery. 

2.  Total  and  partial  retention  of  the  appendages.  When  an 
abundant  haemorrhage  occurs  without  apparent  cause  some  days 
after  accouchement,  the  possibility  of  this  cause  should  always  be 
remembered. 

3.  Uterine  deviation  (especially  retrodeviation)  may  also  cause 
an  obstinate  haemorrhage. 


390 


Accidents  of  Post-Part  am. 


4.  Uterine  inversion,  unrecognized  at  the  moment  of  delivery  or 
produced  later  may  also  produce  a  persistent  and  abundant  haemor- 
rhage. 

5.  Ulceration. — Fibroma,  cancer. 

6.  Metritis. — Subinvolution. — Arrest  of  the  normal  involution, 
the  frequent  cause  of  metritis,  produces  repeated  haemorrhages  of 
slight  abundance. 

7.  Lactation. — At  the  moment  when  the  child  first  takes  the 
breast  a  slight  haemorrhage  is  often  noted,  which  is  repeated  at  each 
nursing  for  some  time.  The  explanation  is  found  in  the  uterine 
contraction  provoked  by  the  irritation  of  the  nipple. 


Fig.  464. — Different  varieties  of  genital  fistula;. 

The  prognosis  of  these  haemorrhages  is  in  general  benign,  ex- 
ceptionally they  become  grave  and  demand  an  energetic  treatment. 

The  treatment  will  vary  essentially  according  to  the  cause  and 
the  abundance  of  the  flow. 

A  slight  haemorrhage  usually  ceases  under  the  influence  of  repose, 
of  hot  vaginal  injections,  of  the  action  of  ergot  or  of  digitalis.  If 
there  exist  uterine  deviation,  metritis,  or  an  inversion,  the  treatment 
appropriate  to  these  various  causes  will  be  applied. 

A  haemorrhage  of  medium  intensity  vvill  generally  be  subdued  by 
the  same  treatment. 

An  abundant  haemorrhage  will  be  due,  at  the  beginning  of  post- 
partum, to  a  secondary  inertia  and  will  require  the  same  treatment 
as  for  inertia  of  delivery  of  the  appendages.  Later,  it  will  be  due 
to  the  existence  of  a  fibroid  or  to  the  retention  of  placental  debris. 
Such  cases  will  require  vaginal  tamponnement  with  iodoform  gauze 
or  curetting  of  the  uterus,  followed  by  intra-uterine  tamponnement. 


The  Vectu  <>r  The  l.>  w  r.  391 

•2.  Fistula. — In  consequence  of  a  prolonged  accouchement,  when 
the  total  head  remains  in  contact  with  the  Bame  point  of  the  partu- 
rient canal  tor  a  prolonged  period,  or  after  a  particularly  difficult 
labor  that  has  caused  grave  traumatisms,  more  or  Less  extended 
necroses  of  the  uterus,  of  the  vagina  or  of  the  contiguous  organs 
are  seen.  The  eschars  arc  cast  of!  six  to  ten  days  alter  accouche- 
ment, establishing  communications  between  the  genital  organs  and 
the  urinary  passages  or  the  intestine  that  are  termed  fistuhe  (Fig. 
4()d).  These  fistulffi  may  also  he  produced  during  accouchement 
by  perforation  caused  by  instruments. 


CHAPTER  XXVIII. 


THE  VECTIS  OR  THE  LEVER. 

he  vectis  was  probably  devised  by  Charnberlan  at  the  same  time 
as  the  forceps.  It  is  composed  of  a  handle  terminated  by  a  fenes- 
trated spoon  (Fig.  465),  recalling  exactly  a  blade  of  the  straight 
forceps. 


m 


Fig.  465. — Ryerson's  adjustable  vectis. 


This  instrument  is  passed  into  the  genital  canal  and  adapted  to 
the  occiput  or  to  one  of  the  parietal  bones  of  the  foetus.  The  handle 
is  then  grasped  with  both  hands  and  given  a  lever  movement,  by 
which  the  foetal  part  is  pushed  toward  the  center  of  the  parturient 
canal. 

Applied  on  the  occiput,  the  lever  produces  flexion  of  the  head ;  on 
one  of  the  parietal  bones,  lateral  inclination,  by  depressing  the  pro- 
tuberance on  which  it  acts. 

At  present,  the  lever  has  been  abandoned  by  all  obstetricians  as 
the  forceps  have  the  preference.  It  has  the  disadvantage  of  being 
only  a  correcting  instrument  (flexing  the  head  or  inclining  it  later- 
ally) and  of  not  admitting  traction  as  with  the  forceps. 


392  Versions. 

In  the  presence  of  this  abandonment  it  is  useless  to  insist  at  length 
on  the  action  of  this  instrument.  However,  it  may  be  again  in 
favor  some  day,  for  if  it  has,  in  relation  to  the  forceps,  the  dis- 
advantage of  not  permitting  a  prompt  termination  of  the  accouche- 
ment, it  is  capable  of  producing'  certain  effects  (flexion,  lateral 
inclination)  that  the  present  forceps  do  not  realize  and  that  are 
valuable  in  a  brow  presentation,  for  example,  or  in  a  narrow  pelvis. 
Bn<-  these  are  new  points  for  future  study  and  illumination. 


CHAPTER  XXIX. 


VERSIONS. 

Version  is  an  operation  which  has  for  its  end  a  modification  of 
the  situation  of  the  foetus  in  the  uterus,  in  such  a  way  as  to  change 
the  presentation  or  to  create  one  when  it  does  not  already  exist. 
This  modification  in  the  fcetal  situation  may  be  obtained  in  three 
ways: 

By  external  manoeuvres,  external  version. 

By  internal  manoeuvres,  internal  version. 

By  mixed  manoeuvres,  mixed  version. 

Independently  of  the  manoeuvres  executed,  version  is  called: 
Cephalic,  when  the  head  is  brought  to  the  superior  strait ; 
Pelvic  or  podalic,  when  the  breech  is  brought  down  to  de- 
termine the  position. 

I.  External  version. 

Three  stages  are  the  same  for  each  variety  of  version: 

1.  To  grasp  the  foetus. 

2.  Fcetal  evolution. 

3.  Fcetal  fixation. 

1.  Grasping  the  foetus  (Fig.  466). — After  determining  the  exact 
situation  of  the  foetus,  a  hand  is  applied  on  each  of  the  poles  of  the 
child,  so  as  to  grasp  it  firmly.  When  the  two  extremities  are  thus 
held,  it  can  be  given  the  desired  movement. 

2.  Foetal  evolution  (Fig.  467). — The  two  pcles  being  grasped  as 
indicated,  the  hands  exert  a  soft  and  progressive  pressure  in  con- 
trary directions,  so  that  the  breech  may  be  directed  toward  the 
fundus  of  the  uterus  and  the  head  brought  to  the  superior  strait  by 
the  shortest  road.     However,  if  difficulties  are  found  in  causing  the 


Versions,  393 

cephalic  extremity  to  descend  in  one  direction,  the  opposite  course 
maybe  taken  in  the  direction  of  leasi  resistance.  During  their 
displacement  the  hands  glide  on  the  .-kin,  which  may  be  smeared 
with  vaseline,  if  necessary. 

^ — w 


Fig.  466. — First  stage.     Grasping  the  foetus. 

3.  Foetal  fixation. — When  the  head  has  been  brought  to  the 
superior  strait,  it  is  necessary  to  fix  it  in  this  new  position,  to 
avoid  return  of  the  vicious  presentation.  For  this  purpose  I  use  a 
belt  furnished  with  four  distinct  cushions  (Fig.  468).  These  pads, 
which  can  be  inflated  separately,  permit  it  to  act  directly  on  the 
breech  and  on  the  head  ;  they  constitute  four  boundaries  fixing  the 
extremities  laterally  and  maintaining  the  child  in  the  desired 
position. 

II.  Mixed  version. 
<i.  PodaMc  version. 

1.  Grasping  the  foetus  (Fig.  470). — The  abdominal  hand  grasps  and 
depresses  the  breech  while  the  vaginal  hand  pushes  up  the  head  of 
the  child ;  from  this  double  action  results  fcetal  evolution.  The  ac- 
coucheur being  placed  on  the  right  side  of  the  woman  applies  the 


394 


Versions. 


left  band  on  the  breech  which  is  grasped  as  in  external  version, 
while  one  or  several  fingers  of  the  right  hand  are  introduced  into 
the  vagina  to  seek  the  fcetal  part. 


FfG.  467. — Second  stage.     Foetal  evolution. 

1.  Fcetal  evolution  (Fig.  471). — The  abdominal  hand  depresses  the 
breech,  while  the  vaginal  hand  pushes  up  the  different  fcetal  parts  as 
they  successively  present  at  the  uterine  orifice.  The  fcetal  evo- 
lution should  be  made  as  much  as  possible  on  its  anterior  or  sternal 


FlG.  468. — (Third  stage.     Foetai  fixation).     Entocie  belt,  with  four 
lateral  dilatable  cushions. 

plane,  for  in  this  way  the  pelvic  members  arrive  at  the  uterine 
opening  more  easily,  where  their  seizure  abridges  the  operation. 


r. .  ions. 


895 


/ 


Fig.  469. — Mobilization  of  the  engaged  foetal  part. 

3.  Foetal  fixation  (Fig.  472). — As  soon  as  one  of  the  small  pelvic 
members  becomes  accessible,  it  is  grasped  through  the  uterire 
orifice  by  one  or  two  ringers  and  brought  down  into  the  vaginal 
cavity. 

b.  Cephalic  version  (Fig.  473). — The  hands  are  placed  in  a  similar 
manner.  The  evolution  is  made  in  the  opposite  direction  to  that 
of  podalic  version,  that  is,  by  depressing  the  head  and  pushing  up 
the  breech  first,  and  then  the  different  foetal  parts  successively,  as 
they  become  accessible.  Fixation  is  made,  as  in  cephalic  version, 
by  external  manoeuvres. 


III.  Internal  version. 

1.  Seizure  of  one  or  more  foetal  parts. — The  aim  will  be  to  .grasp  one 
or  both  feet  of  the  child  and  bring  them  to  the  vulva.  This  com- 
prehends a  series  of  secondary  questions  which  will  be  touched 
upon  successively  as  follows  : 

The  hand  to  lie  introduced; 

The  mode  of  introducing  the  hand ; 


396 


Versions. 


Fig.  470. — External  podalic  version.     First  stage  (Braxton  Hicks). 


FlG.  471. — External  podalic  version.     Second  stage  (Braxton  Hicks). 


Versions. 


897 


FIG.  472.— External  podalic  version.     Third  stage  (Braxton  Hicks). 


Fig  473. — External  cephalic  version. 


398 


Versions. 


Fig.  474. — Internal  podalic  version.     Grasping  the  feet  in  thorax 
presentation  (dorso-anterior). 


Fig.  475. — Internal  podalic  version.     Grasping  the  feet  in  thorax 
presentation  (dorso-posterior). 


Version*. 


:)!i'.) 


The  search  for  the  feet; 

The  seizure  of  the  feet. 

The  hand  to  be  introduced. — I  always  introduce  the  ri^rlit  hand 
first,  ami  if,  by  hazard,  I  fail  to  grasp  the  feet,  it  is  withdrawn  and 
the  left  replaces  it.  I  prefer,  in  the  exceptional  cases  in  which  it 
becomes  necessary,  to  preform  this  double  manoeuvre,  which  is 
without  inconvenience  to  the  anaesthetized  woman,  rather  than  to 
torture  the  memory  with  a  series  of  principles  for  the  most  part 
useless. 


Fig.  476. — Internal  podalic  version.     Grasping  the  feet  in  vertex  presentation. 

The  mode  of  introducing  the  hand. — The  hand,  smeared  with  vase- 
line over  all  its  dorsal  region,  takes  the  form  of  a  cone.  With  this 
configuration  favorable  to  penetration,  the  hand  is  passed  tlnough 
the  vagina  to  the  cervix.  The  cervix  should  be  sufficiently  dilated 
to  allow  the  hand  to  pass  (a  requisite  condition  for  internal  version ) ; 
complete  dilatation  is  only  indispensable  for  extraction.  Arrived 
at  the  cervix  the  hand  meets  the  bag  of  waters  when  it  is  yet  intact ; 
this  must  be  ruptured  before  penetrating  into  the  uterus. 

The  search  for  the  feet. — What  direction  should  the  hand  follow  to 
arrive  most  easily  at  the  feet  of  the  child  ?    The  pelvic  members 


400 


Versions. 


being,  save  very  rare  exceptions,  flexed  and  folded  along  the 
anterior  plane  of  the  fcetus,  it  is  by  following  this  sterno-unibilical 
plane  that  they  are  most  easily  found  (Figs.  474,  475,  476,  477). 

The  seizure  of  the  feet. — If  the  two  feet  are  easily  found,  they  are 
grasped  and  drawn  down  to  cause  evolution  of  the  foetus;  but  in 
case  only  one  foot  can  be  found,  it  is  useless  to  delay  to  seek  a  second, 
for  the  single  foot  is  perfectly  sufficient  to  execute  version. 


Fig.  477. — Internal  podalic  version.     Second  stage.     Foetal  evolution. 

2.  Foetal  evolution. — For  evolution  it  is  necessary  to  exert  traction 
on  the  foot  or  feet  grasped,  to  draw  the  parts  outward.  At  first 
there  will  be  felt  a  certain  resistance,  then  if  evolution  is  possible 
the  foot  or  feet  descend,  drawing  down  the  breech,  and  thus  pro- 
ducing evolution. 

The  tractions  for  evolution  as  well  as  the  progression  of  the  hand, 
in  the  first  stage,  should  only  proceed  during  the  intervals  of  the 
uterine  contractions. 

The  hand,  which  during  the  first  stage  was  placed  on  the  fundus  of 
the  uterus  to  maintain  it,  should  aid  evolution,  either  by  supporting 
the  breech  or  by  pushing  the  head  toward  the  fundus  of  the  uterus. 

3.  Festal  fixation. — This  third  stage  is  without  importance  here, 


Versions.  401 

for,  if  the  dilatation  is  complete,  version  is  generally  terminated  by 
extraction;  it'  not,  it  i-  sufficient  to  leave  the  foot  or  feet  in  the 
vagina  or  at  the  vulva. 
Prognosis. — The  prognosis  of  the  different  versions,  for  the  mother 

and  for  the  child,  depends  upon  : 
The  operator ; 

The  variety  of  the  version  employed; 
The  circumstance  proper  to  each  particular  case. 

The  operator  should  he  experienced  and  aseptic. 

In  a  general  manner  the  gravity  of  each  variety  of  version  be- 
comes less  as  there  is  less  penetration  into  the  genital  organ.-. 
Internal  version  is  the  most  serious  and  external  the  most  benign. 

With  regard  to  the  different  circumstances  which  may  cause 
variations  in  the  prognosis,  they  are  too  numerous  to  mention. 
Complications  and  difficulties  may  arise  that  will  produce  a  very 
grave  prognosis. 

However,  we  may  say  that  when  properly  performed  and  executed 
at  the  correct  moment,  these  different  versions  usually  permit  us 
to  save  the  mother  and  the  child,  and  that  they  constitute  one  of 
the  most  valuable  resources  of  obstetrics. 


402 


Forceps. 


CHAPTER  XXX. 


FORCEPS. 

The  forceps  is  a  sort  of  pincers  with  separable  blades  used  to 
grasp  the  foetus  and  extract  it  from  the  genital  canal.  There  are 
many  varieties  of  forceps,  but  we  may  separate  them  into  three 
classes. 


Fig.  480  — Unicurved  forceps.     XVIIth  century  (Chamberlan 


1.  The  unicurved  forceps. — The  first  forceps,  devised  by  Cham- 
berlan (Fig.  480),  possessed  a  single  curve,  the  cephalic  curve,  and 
was  thus  a  unicurved  forceps.  Like  all  the  instruments  of  the 
present  day  it  is  composed  of  two  branches,  each  divided  into  a 
handle,  a  blade,  and  an  intermediate  part,  or  articulation.  The  two 
halves  of  the  instrument  are  called  the  right  and  left  blades,  and 
also  the  male  and  female  blades ;  the  left  branch,  or  male  blade, 
bearing  the  pivot  of  the  articulation.  These  denominations  should 
be  remembered  as  they  will  be  constantly  met  in  the  descriptions 
which  follow. 


2.  The  hicurved  forceps. — The  priority  of  this  modification  belongs 
to  Levret  (Fig.  482),  who,  in  1747,  published  a  description  of  a 
forceps  with  two  curves,  one  cephalic,  the  other  pelvic,  seen  on  ex- 
amining the  instrument  in  detail.  The  various  Incurved  forceps  of 
the  present  day  are  designed,  like  those  of  Levret,  with  one  curve, 
adapted  to  the  head,  the  other  to  the  pelvis. 


Forceps. 


403 


3.  The  tricwrved  forceps. — The  most  complete  forceps  of  this  class 
was  that  produced  by  Tarnier,  in  1877.  La  a  general  way  it  resembles 
that  of  Levret,  but  (litters  in  three  principal  points  (Figs.  188  and 

484): 

1.  By  the  presence  of  a  pressure  screw,  placed  at  the  side  of  the 
articulation,  to  supplement  the  action  of  the  hands  in  keeping  the 

handles  together; 

2.  By  the  addition  of  two  movable  rods,  destined  to  traiiMuit  the 
traction ; 

3.  By  a  traction  handle  fitted  to  the  preceeding,  and  designing 
the  perineal  curve. 


Fig.  482. — Bicurved  forceps  (Levret). 

From  this  disposition,  the  tricurved  forceps  presents  the  follow- 
ing advantages : 

1.  It  permits  traction  in  the  axis  of  the  genital  canal. 


Fir,.  4S3. — Tarnier's  axis-traction  forceps. 

•2.  It  allows  the  head  its  molality,  since  the  tractions  are  made 
by  an  apparatus  articulating  with  the  blades  which  are  thus  left  to 
themselves,  after  fixation  with  the  pressure  screw. 


404 


Forceps. 


3.  It  possesses  an  indicating  needle,  constituted  by  the  handles, 
which,  by  showing  the  movements  of  the  still  invisible  head,  is 
valuable  in  pointing  out  the  direction  in  winch  the  tractions  should 
be  exercised. 


Fig.  484. — Tricurved  forceps. 

The  different  types  of  forceps,  so  far  studied,  are  those  with 
crossed  branches,  but  there  is  also  another  variety  with  parallel 
branches.  Like  the  first  variety  we  have  described,  forceps  with 
parallel  branches  may  be  divided  into  three  principal  types :  the 
unicurved  (Fig.  485),  the  bicurved  (Fig.  486)  and  the  tricurved  (Fig. 
487).  For  mechanical  reasons  forceps  with  parallel  branches  do 
not  exert  as  great  a  compression  on  the  fcetal  part  between  the 
blades  as  the  crossed  forceps,  yet  their  employment  is  not  common 
at  present,  and  I  leave  them  out  of  consideration,  together  with  a 
series  of  various  models,  which  only  realize  ingenious  ideas. 

Application  of  the  forceps. 

It  is  indispensable  to  divide  this  study  into  two  parts : 
a.  The  general  application  of  the  forceps. 
//.  The  particular  applications. 

a.  General  application. — There  are  three  successive  stages: 

1.  Introduction. 

2.  Articulation. 

3.  Extraction. 

First  stage. — There  are  three  rules  relating  to  the  introduction 
of  the  forceps,  the  first  concerning  the  mother,  the  second  the  child, 
and  the  third  the  forceps. 


Forceps. 


405 


1.  Maternal  rule. 

Right  branch,  grasped  with  the  right  hand,  introduced  to  the  right 
of  the  woman. 

Left  branch,  grasped  with  the  left  hand,  introduced  to  hit  of  the 

woman. 


Fig.  4S5. 


Fig.  4S6. 


Porallel  unicurved  forceps     Parallel  bicurved  forceps 
(Thenance,  1781).  (Valette,  1857). 


Fig.  487. 

Parallel  tricurved  forceps 
(Poullet). 


•2.  Foetal  rule. 

The  child  should  be  grasped  from  one  ear  to  the  other.  If  there 
ia  a  presentation  of  the  cephalic  ovoid  the  diameter  grasped  should 
be: 

The  biparietal  for  the  vertex  ; 
The  bimalar  for  the  face ; 
The  bitemporal  for  the  brow. 

In  cases  of  breech  presentation  the  bitrochanteric  diameter  will 
be  chosen. 


406 


Forceps. 


3.  Instrumental  rule. 

The  left  branch  is  always  to  be  applied  first,  thus  avoiding  cross- 
ing the  handles  in  articulating. 


Fig.  488.— Introduction  of  the  left  blade. 


Fig.  480. — Left  blade  introduced. 


Forceps. 


407 


Such  arc  the  rales  for  the  introduction  of  the  forceps.  Let  us 
now  put  them  into  execution  by  taking,  as  an  example,  the  most 
simple  ease,  a  vertex  presentation  in  the  occipito-pubic  position, 

the  head  at  the  vulva. 


Fig.  490. — Introduction  of  the  right  blade. 

Introduction  of  the  left  branch  (Figs.  488,  489).— The  left  blade  is 
held  in  the  left  hand  as  indicated  in  Fig.  488.  Two  lingers  of  the 
right  hand  are  introduced  at  the  lateral  and  intent  >r  part  of  the  vulva. 
(When  the  head  is  higher  up  it  is  Letter  to  introduce  four  fing 
to  seek  the  cervix  and  thus  to  avoid  perforation  of  the  culs-de-sac 
with  the  blades.)  The  instrument  is  made  to  penetrate  backward 
and  laterly,  and  brought  gently  to  the  side  of  the  head  in  the  position 
it  should  occupy  definitely  (Fig.  489). 

Introduction  of  the  right  branch  (Figs.  490,  491  h— The  right  branch 
is  held  in  the  right  hand,  the  left  hand  serving  to  guide  the  blade, 
and  introduced  into  the  genital  organs  above  the  branch  already 
placed. 


408 


Forceps. 


FlG.  491. — Right  blade  introduced. 


Fig.  492. — Articulation-     Locking. 

Second  stage. — To  proceed  to  articulation,  that  is  to  say,  to  lock- 
ing of  the  two  blades  (Fig.  492),  each  handle  is  grasped  and  after 
crossing,  if  necessary,  parallelism  of  the  branches  is  established. 


Foxo  p8. 


41)-.  I 


The  pivot  of  the  male  branch  is  made  to  penetrate  into  the  mortise 
of  the  female  branch  and  the  blades  are  made  secure  by  tightening 
the  screw  (Fig.  498). 


Fig.  493. — Articulation.  Application  of  the  screw  (the  handles  at  this  moment 
should  be  horizontal.  In  Figs.  492,  493  they  are  inclined  backward  to  show  the  de- 
tails of  the  operation.  • 

After  articulation  of  the  forceps,  before  proceeding  to  extraction, 
examination  is  made  to  be  sure  that  the  head  is  well  grasped  and 
grasped  alone.  If  a  loop  of  the  cord  or  other  part  is  included 
between  the  blade  and  the  foetal  part,  the  forceps  must  be  removed, 
or  at  least  the  part  badly  applied,  for  reintroduction.  The  forceps 
should  be  removed  in  the  following  manner.  After  unlocking,  the 
right  branch  is  retired  by  making  it  follow  gently  a  passage  ab- 
solutely the  inverse  of  that  of  introduction,  then  the  left  branch  is 
withdrawn  in  the  same  way. 

Third  stage. — Supposing  the  forceps  to  be  properly  applied  we 
may  proceed  with  extraction.  The  forceps  is  grasped  with  both 
hands  (Fig.  494),  the  left  below,  the  right  above  and  nearer  the 
vulva,  so  as  to  give  the  instrument  a  lever  movement,  indispensable 
for  traction  in  the  axis. 

At  the  moment  when  the  head  opens  the  vulva,  the  forceps  is  held 
with  one  hand  (Fig.  495),  progressively  elevating  the  handle  so  as 


410 


Forceps. 


to  give  a  movement  of  extention  to  the  cephalic  extremity.  The 
thumb  of  the  other  hand  is  applied  on  the  perinseum,  supporting 
the  festal  head  and  moderating  the  rapidity  of  the  exit,  so  as  to  avoid 
laceration. 


Fig.  494. — Extraction.     Arrival  of  the  head  at  the  vulvar  orifice. 


FlG.  495. — Extraction.     The  head  opens  the  vulvar  orifice. 


Forceps. 


411 


6.  Particular  applications.  —  The  forceps  may  be  applied  on  the 
verti  x,  the  face,  the  brow,  the  breech,  or  the  head  last. 


Fig.  496. — Rotation  of  the  blades  upon 
the  axis  of  the  handle  (bicurved  forceps). 


Fig.  497 — Rotation  of  the  blades  upon 
their  txis  (tricurved  forceps). 


I.  Vertex. 

When  the  total  part  arrives  in  the  soft  pelvis  it  may  still  be 
found  in  the  excavation  or  at  the  superior  strait. 

1.  Soft  pelvis  (from  the  median  strait  to  the  vuiva). — Direct  appli- 
cation. The  vertex  on  arriving  at  this  region  is  generally  placed 
in  0  P,  exceptionally  in  0  S. 

0  P. — This  is  the  easiest  application  of  the  forceps,  that  which  we 
have  taken  as  a  type  and  already  described. 

0  S.  — The  forceps  is  placed  as  on  a  head  in  0  P,  and  extraction 
may  be  made  in  two  ways,  either  in  occipito-sacral  or  in  occipito- 
pubie,  by  giving  the  head  a  movement  of  rotation  designed  to  bring 
the  occiput  forward. 

When  rotation  can  be  made  it  is  preferable.  This  movement 
should  be  made  by  causing  the  handles  to  describe  the  arc  of  a 


412 


Forcejis. 


circle  (Fig.  497).  Rotation  of  the  blades  in  the  arc  of  a  circle  (Fig. 
496)  must  be  avoided  on  account  of  the  injury  it  would  cause  to  the 
maternal  parts. 

2.  Excavation. — Oblique  application. — The  sagital  suture  is  placed 
in  relation  to  one  of  the  oblique  diameters. 

L  0  I  A. — Left  blade  to  the  left  and  backward.  Right  blade,  in- 
troduced to  right  and  backward,  then  brought  forward  and  to  the 
right  by  a  spiral  movement  (Fig.  498). 


Fig.  498. — Spiral  movement. 

L  0  I  P. — Left  blade,  to  the  left  and  forward.  Right  blade,  to 
the  right  and  backward.  Movement  of  rotation  to  bring  the  occiput 
forward  by  the  shortest  way.  After  this  movement  of  rotation  the 
forceps  is  found  placed  in  the  opposite  direction  and  if  extraction 
cannot  be  terminated  they  must  be  removed  and  reapplied.  In 
case  rotation  is  impossible,  extraction  in  0  S  is  made. 

R  0  I  A. — Left  blade,  to  the  left  and  forward.  Right  blade,  to  the 
right  and  backward,  the  occiput  is  brought  forward  and  extracted. 

R  0  I  P. — Left  blade,  to  the  left  and  backward.  Right  blade,  to 
the  right  and  forward.  Movement  of  rotation  to  bring  the  occiput 
forward  for  extraction  in  0  P.  If  rotation  is  impossible,  extraction 
inO  S. 

3.  Superior  strait ;. — Transverse  application.  Three  ways  of  seizing 
the  head  present : 

Biparietal ; 

Occipitofacial; 

Parietofrontal. 

The  biparietal  method  of  grasping  the  head,  while  the  best  in 
theoretical  point  of  view,  presents  in  practice  serious  disadvantages, 
it  -  relative  difficulty,  the  increase  in  diameter  by  the  application  of 


Fon  41G 

the  blades,  and  tho  prevention  of  tbe  oscillation  of  this  diameter 
during  descent  through  a  contracted  superior  strait.  Thus  the  two 
other  methods  of  Beizure  are  preferable.  A-  a  rule  the  occipito- 
facial should  be  ased,  and  iii  case  it  fails  the  parieto-facial  method 
should  be  attempted,  the  biparietal  Beizure  bene  reserved  for 
relatively  rare  cases  and  for  a  special  form  of  pelvis. 

L  0  I  T. — Tbe  left  blade  to  the  occiput,  the  right  on  the  face. 
The  head  is  made  to  descend  into  the  excavation  in  the  transv 
position;  it  Is  placed  in  OP  at  the  median  strait,  and  from  this 
moment,  according  to  the  suppleness  of  the  soft  tissues,  the  ex- 
traction is  terminated  by  leaving  the  forceps  in  position  or  by 
reapplying  the  blades  to  grasp  the  biparietal  diameter. 

R  0  I  T. — Left  blade  on  the  face ;  right  blade  on  the  occiput.  The 
head  is  made  to  descend  into  the  excavation  in  the  transverse 
position.  The  occiput  is  then  brought  forward  and  extraction 
terminated  as  in  L  0  I  T. 

II.  Face. 

1.  Soft  pelvis. — Direct  application. 

M  P. — Same  application  as  in  0  P.  Extraction  conforming  to 
the  normal  mechanism. 

M  S. — Same  application  as  for  M  P.  In  extraction  the  chin  must 
be  brought  forward. 

2.  Excavation.  —  Oblique  application.  All  that  has  been  said 
apropos  of  vertex  presentation  applies  here,  with  the  difference  that 
it  is  always  necessary  to  bring  the  chin  forward. 

3.  Superior  strait. — Transverse  application.  "When  the  head  in 
face  presentations  is  still  at  the  level  of  the  superior  strait,  it  is 
much  better  to  use  podalic  version,  or  reduction  of  the  face  into 
vertex,  followed  by  application  of  the  forceps,  if  necessary. 

However,  if  in  these  conditions  it  is  desired  to  apply  the  forceps, 
it  will  be  preferable  to  apply  the  blade  of  the  forceps  on  the  bi- 
malar  diameter;  but  this  intervention  is  not  to  be  advised. 

III.  Brow. 

1.  Soft  pelvis. — Direct  application.  The  forceps  may  be  applied 
from  one  ear  to  the  other  and  the  head  extracted  directly  by  imi- 
tating the  mechanism  of  a  normal  exit  as  much  as  possible. 

2.  Excavation. — Oblique  application.  Apply  the  forceps  as  in  an 
analogous  presentation  of  the  vertex,  after  having  attempted  trans- 
formation into  a  vertex. 

3.  Superior  strait. — Transverse  application.  Attempt  transfor- 
mation into  vertex  or  internal  podalic  version,  if  the  conditions  are 
favorable;  if  not,  apply  the  forceps  as  if  in  presentation  of  the 
vertex  and  make  extraction  by  bringing  the  occiput  forward. 


414 


Forceps. 


IV.  Breech. 

The  forceps  will  only  be  indicated  in  presentation  of  the  breech, 
variety  of  the  buttocks ;  in  all  other  cases  the  feet  will  be  seized 
and  manual  extraction  performed  by  preference. 

To  apply  the  forceps  on  the  breech,  grasp  the  bitrochanteric 
diameter  and  perform  extraction  by  imitating  the  normal  mechan- 
ism of  accouchement. 

V.  Head  last. 

The  after-coming  head  may  be  retained: 

By  the  bony  pelvis ; 

By  the  cervico-uterine  segment; 

By  the  soft  pelvis. 

In  the  first  case  the  forceps  is  a  bad  method  of  extraction ;  the 
hand  is  preferable. 

In  the  second  case,  the  forceps  is  relatively  better,  but  manual 
extraction  is  more  certain. 


Fig.  499. — Extraction  with  the  tricurved  forceps, 
at  the  vulvar  orifice. 


Arrival  of  the  head 


In  the  third  case,  where  the  hands  are  insufficient  the  forceps  is 
a  valuable  resource  of  extraction.  To  apply  the  instrument  in 
such  a  case,  it  is  sufficient,  after  having  brought  the  occiput  for- 
ward, to  have  the  child's  body  uplifted  by  an  assistant  and  to  glide 
each  one  of  the  blades  on  to  the  lateral  parts  of  the  cephalic  ex- 
tremity, as  in  head  first.  Disengagement  is  performed  by  giving 
the  foetal  part  a  hinge  movement  around  the  lower  part  of  the 
symphysis  pubis,  the  occipitocervical  groove  remaining  in  contact 
with  the  maternal  pubis. 

■1.  Tricurved  forceps. — The  introduction  of  the  blades  is  made  ac- 
cording to  the  same  principles  as  for  the  bicurved  forceps. 


Forceps. 


11.-, 


Articulation  should  be  completed  by  the  fixation  of  the  pressu  *e 

screw  and  adaptation  of  the  traction  handle  and  rods. 

Extraction  takes  place  simply  by  grasping  the  traction  apparatus, 
leu  ving  free  the  forceps  handles  as  an  indicator.  It  is  necessary 
to  exercise  traction  (Fig.  499)  in  such  a  way  that  between  the 
handles  of  prehension  and  the  traction  handle  there  will  be  an 
interval  of  about  a  finger's  breadth. 


Fig.  500. — Extraction  with  the  tricurved  forceps.     The  head  opens 
the  vulvar  orifice. 

At  the  moment  when  the  head  opens  the  vulva,  the  forceps  are 
grasped  with  the  left  hand  (Fig.  500)  while  the  right  supports  the 
perinaeum. 

To  accomplish  rotation  with  the  axis  traction-forceps,  one  hand 
should  hold  the  traction  apparatus  while  the  other  gives  a  turning 
movement  to  the  handles,  causing  them  to  describe  a  rotation 
around  the  traction  rods  as  a  center. 


416  Manual  Extraction. 


CHAPTER  XXXI. 


MANUAL  EXTRACTION. 

When  the  foetus  presents  by  the  breech  the  obstetrician  may,  by 
grasping  the  pelvic  members  with  the  hand,  practice  extraction  in 
the  same  way  as  with  the  forceps  in  a  presentation  of  the  cephalic 
ovoid.  Thus,  besides  extraction  by  the  forceps,  there  exists  manual 
extraction,  which  must  not  be  confounded  with  podalic  version. 

In  preparing  for  manual  extraction  the  patient  should  be  placed 
in  the  obstetrical  position  as  for  the  forceps  and  internal  version. 
Anesthesia  is  used  or  not  according  to  the  woman  and  to  the 
assistants  at  disposal. 

The  operation  is  performed  in  three  stages : 

1.  Grasping  the  feet. 

2.  Extraction  of  the  trunk. 

3.  Extraction  of  the  head. 

First  stage. — The  right  hand  is  introduced  into  the  genital 
organs  to  grasp,  according  to  the  facility,  one  foot  alone  or  both 
feet.  If  extraction  succeeds  to  internal  version,  this  first  stage  is 
found  already  executed. 

Second  stage. — During  the  whole  of  the  extraction  an  assistant 
supports  the  fundus  of  the  uterus  and  compresses  it  with  both  hands. 

Lower  limbs  (Fig.  506). — The  limbs  are  grasped  with  both  hands 
and  drawn  strongly  downward  in  the  supposed  direction  of  the  axis 
of  the  superior  strait. 

Breech  (Fig.  507). — As  soon  as  the  breech  appears  at  the  vulva, 
it  is  grasped  with  both  hands,  covering  it  with  a  cloth,  at  need,  to 
prevent  slipping.     The  tractions  are  continued. 

Abdomen  (Fig.  508). — The  abdomen  is  disengaged  without  re- 
moving the  hands  from  the  breech.  It  should  never  be  grasped 
with  the  hand  on  account  of  the  lesions  that  might  be  thus  produced. 
As  soon  as  the  cord  becomes  visible,  its  placental  extremity  should 
be  drawn  out  to  constitute  a  loop  that  will  avoid  the  dragging  to 
which  it  will  be  exposed  without'this  precaution. 

Thorax. — The  tractions  on  the  breech  are  continued,  directing  the 
vertebral  column  toward  the  middle  of  the  ischio-pubic  ramus  in 
such  a  manner  that  the  head  on  arriving  in  the  excavation  is  placed 
easily  and  naturally  in  the  0  P. 

Thibd  stage. — When  the  head  is  small,  well  flexed,  the  genital 
passage  large  and  supple,  and  when  the  abdominal  expression  lias 


Manual  Extraction. 


417 


Fig.  506. — Grasping  the  inferior  members. 


Fig.  507. — Grasping  the  breech. 


418 


Manual  Extraction. 


been  well  made,  it  sometimes  happens  that  the  cephalic  ovoid,  after 
the  expulsion  of  the  shoulders,  makes  a  sudden  exit  from  the  genital 
organs,  as  if  ejaculated. 


Fig.  508. — Liberation  of  the  cord. 


Fig.  509. — Manual  extraction,  exit  of  the  head. 

But  usually  it  becomes  necessary  to  assist  its  exit  by  introducing 
one  or  two  fingers  in  the  child's  mouth,  placing  the  other  hand  on 
the  neck  (Fig.  509).     The  tractions  made  by  the  two  hands  thus 


Manual  Extraction. 


419 


placed  should  tlex  the  head  and  give  it  a  binge  movement  around 
the  occipitocervical  groove  placed  under  the  maternal  pub 


Fig.  510. — Manual  extraction,  drawing  down  the  posterior  arm. 

There  may  also  be  difficulties  in  extraction  caused  by  uplifted 
arms.  In  this  complication,  drawing  on  the  child  in  the  hope  of 
seeing  the  head  and  arms  expelled  simultaneously  must  be  guarded 
against.  If  this  is  done,  extraction  will  become  impossible  except 
with  a  relatively  small  child.  It  is  necessary  to  draw  the  aims 
down  successively,  in  a  different  manner,  according  as  the  head  has 
arrived  at  the  median  strait  or  is  still  retained  at  the  superior  strait. 


Fig.  511. — Manual  extraction,  drawing  down  the  anterior  arm. 

1.  Head  at  the  median  strait. — Commence  by  disengagement  of 
the  posterior  arm  (Fig.  510).  After  strongly  uplifting  the  child  the 
ringers  are  introduced  into  the  vagina  to  grasp  the  arm.  Placing 
the  fingers  parallel  to  the  humerus  the  arm  is  drawn  down  by 
making  it  follow  the  inverse  movement  of  raising  it  up  (Fig.  511). 


420  Induced  Expulsion. 

2.  Head  at  tltc  superior  strait. — When  the  head  is  retained  at  the 
superior  strait,  by  a  contracted  pelvis  for  example,  it  is  necessary 
to  proceed  to  the  same  successive  disengagement  of  each  arm,  but 
here,  in  place  of  beginning  with  the  posterior  shoulder,  it  is  better 
to  extract  the  anterior  first,  for  it  is  only  separated  from  the  hand 
by  the  height  of  the  pubes,  while  the  posterior  shoulder  being  found 
at  the  promontory  it  would  be  necessary  to  follow  the  perinaeum^ 
the  coccyx  and  the  sacrum. 


CHAPTER  XXXII. 


INDUCED   EXPULSION. 

Premature  expulsion  should  be  performed : 

1.  When  there  is  a  disproportion  between  the  parturient  canal 
and  the  foetus.  Causes  :  Pelvic  deformity,  excess  of  volume  of  the 
foetus,  or  both  combined. 

2.  When  there  are  indications,  other  than  these,  furnished  by  the 
mother  or  by  the  foetus. 

Mother  — 

Any  grave  condition  capable  of  being  modified  for  the  better  by 
the  interruption  of  pregnancy  becomes  an  indication  for  induced 
expulsion.     Such  are : 

Incoercible  vomiting. 

Grave  or  pernicious  anaemia. 

Any  grave  disease  of  the  lungs  (asphyxia),  of  the  heart  (asystole), 
or  of  the  kidneys,  menacing  the  existence  of  the  woman  and  capable 
of  being  relieved  by  the  expulsion  of  the  ovum. 

Fcetus. — 

The  foetal  indication  is  furnished  by  that  pathological  state  which 
we  have  studied  under  the  term  habitual  death.  In  such  cases  we 
are  authorized  to  induce  premature  labor  to  save  the  child.  This 
indication  disappears  if  the  death  precedes  the  last  three  months 
of  pregnaiK-y. 

Contraindications. — The  contraindications  are  three  in  number. 

1.  The  death  of  the  foetus. 

2.  The  grave  condition  of  the  mother,  capable  of  fatal  termination 
under  induced  expulsion.     If  the  operation  is  to  save  the  child, 


Induced  Expulsion,  421 

being  given  the  imminenl  death  of  the  mother,  it  is  better  to  wait 
a  favorable  momenl  for  Csesarian  section. 

3.  The  formal  will  of  the  mother,  who,  in  full  possession  of  her 
faculties,  desires  to  save  the  child  by  going  to  term  and  submitting 

to  ;i  ( Isesarian  section. 

The  different  methods  which  have  been  proposed  for  the  in- 
duction of  premature  expulsion  may  be  classed  in  the  following 
manner : 


I.  Indirect  methods 
I.  Internal. 


f  I.  Ancient  authorities,  rue,  yeu,  sabina. 

|  2.  Bongiovanni,  ergot. 

1  3-  Sayre,  sulphate  of  quinine. 

[  4.  Mui-Autet,  pilocarpine  hydrochlorate. 

f  1.  D'outrepont,  uterine  frictions,  massage. 

-,  ,     I    2.  Schreiber,  Simpson,  faradization. 

'   j    3.  Gardien,  repeated  hot  baths. 

[  4.  Friedreich,  Scanzoni,  sinapisms,  cups  to  the  breasts. 

II.  Direct  methods. — 

(I>  Schoeller,  vaginal  tampon. 
2.  Huter,  Braun,  colpeurynter. 
3.  Kiwish,  douches  to  the  cervix. 

{1.   Kluge,  prepared  sponge. 
2.  Van  Leynseele,  laminaria. 
3.  Barnes,  Chassagny,  rubber  Sac. 

3.  In  the  uterus: 

f  1.  Krause,  elastic  sound. 

a    Non-dilatable  bodv    -!   2<  Schweighauser>  utero-ovuline  injection. 

*'   1    3.  Hamilton,  detachment  of  the  membranes  with 
the  finger. 

ii.  Tarnier,  rubber  bag. 
2.  Pajot,  Tarnier's  dilator  modified. 
3.  Champetier  de  Ribes,  inextensible  bag. 

(I.  Scheel,  trocar  (perforation  of  the  membranes  at  the  cervix). 
2.  Meissner,  trocar  (perforation  of  the  membranes  at  a  point 
distant  from  the  cervix). 

Among  these  numerous  methods,  the  three  best  procedures  for 
inducing  premature  expulsion  of  the  ovum  are,  the  perforation  of 
the  membranes  and  the  introduction  into  the  uterus  of  a  dilatable 
or  a  non-dilatable  body. 

Perforation  of  the  membrane  has  the  disadvantage  of  depriving 
the  foetus  of  a  part  of  its  amniotic  liquid  and  thus  of  exposing  in  a 
greater  degree  to  the  dangers  of  accouchement.  Therefore,  unless 
it  relates  to  abortion,  where  the  life  of  the  child  is  indifferent,  it  is 
better  to  give  the  preference  to  one  of  the  two  methods  which  follow : 

The  introduction  of  a  dilatable  body  is  happily  realized  by 
Tarnier's  rubber  bag,  carried  into  the  uterus  by  the  aid  of  a  special 
instrument ;  but  this  apparatus  is  quite  complicated,  the  bag  some- 
times bursts,  an  accident  necessitating  the  introduction  of  a  new 
dilator.     Ribes  has  recently  advised  a  dilator  of  inextensible  tissue, 


422 


Induced  Expulsion. 


that  is,  dilatable  only  to  a  certain  extent ;  this  dilator  has  the  ad- 
vantage of  promptly  inducing  labor  and  of  causing  a  rapid  opening 
of  the  cervix,  but  the  relative  difficulty  of  its  introduction  into  the 
uterus,  the  dangers  of  the  vicious  presentations  to  which  it  exposes 
and,  finally,  the  frequent  procidence  of  the  cord  as  a  consequence 
of  its  introduction,  will  prevent  its  coming  into  common  use. 


Fig.  512.  —  Sound  introduced  into  the  uterus  and  folded  in  the  vagina 
(Krause's  procedure). 

Introduction  of  a  non-dilatable  body. — The  most  simple  and  the  best 
procedure  is  that  advised  by  Krause,  which  consists  of  introducing 
a  simple  sound  or  elastic  bougie  into  the  uterus  (Fig.  512).  The  two 
accidents  that  may  be  observed  during  the  introduction  of  the  in- 
strument are,  perforation  of  the  membrane  and  a  haemorrhage 
proceding  from  a  traumatic  detachment  of  the  placenta. 

The  first  is  a  simple  annoyance ;  the  second  may  be  left  or  be 
withdrawn,  as  expulsion  will  be  induced  by  the  perforation  of  the 
membranes.  The  haemorrhage  resulting  from  a  placental  detach- 
ment is  a  more  serious  complication ;  it  is  necessary  to  withdraw 
the  instrument  and  to  attempt  its  introduction  in  a  new  direction. 
If  the  flow  of  blood  continues  or  takes  serious  proportions  it  may 
become  necessary  to  apply  the  treatment  advised  for  placenta 
prsevia. 

The  bougie  demands  watching,  for  under  the  influence  of  uterine 
contractions  it  is  sometimes  expelled  into  the  vagina  and  needs  to 
be  introduced  again. 


Embryotomy, 


CHAPTER  XXXIII. 


EMBRYOTOMY. 

When  the  foetus  is  too  voluminous  to  pass  through  the  parturient 
canal  it  becomes  necessary,  unless  we  resort  to  Caesarian  section, 
to  extract  it  by  reducing  it  at  the  sacrifice  of  its  existence.  This 
operation  is  called  embryotomy. 

According  as  the  foetus  presents  by  the  head  or  by  the  trunk,  the 
reduction  will  relate  to  one  or  the  other  part ;  we  have,  then,  two 
varieties  of  embryotomy : 

Cephalic  embryotomy,  reduction  of  the  head. 

Cormic  embryotomy,  reduction  of  the  trunk. 

The  trunk,  like  the  head,  is  composed  of  viscera  enclosed  in  a 
more  or  less  resisting  wall.  Now,  embryotomy  is  sometimes  ad- 
dressed to  one,  sometimes  to  both,  of  these  two  elements — viscera 
and  wall.  In  this  point  of  view  there  are  also  two  varieties  of 
embryotomy : 

Visceral  embryotomy. 

Parietal  embryotomy. 

Visceral  embryotomy  consists,  for  the  cephalic  ovoid,  in  the 
evacuation,  after  perforation  of  the  cranium,  of  the  cerebral  sub- 
stance, and  for  the  cormic  ovoid,  in  tearing  away  the  viscera  oc- 
cupying the  thoracic  and  abdominal  cavities  after  perforation.  In 
both  cases  it  is  an  evisceration  differing  only  by  the  organs  to  which 
it  relates. 

Parietal  embryotomy  for  both  ovoids,  consists  in  reduction  of  the 
size  in  four  different  ways  : 

By  compression — which  is  exerted  on  the  eviscerated  ovoid  by  the 
forceps  or  by  an  analogous  instrument. 

By  accommodation — when,  for  example,  with  the  aid  of  the  crani- 
oclast,  a  perforated  head  is  drawn  slowly,  or  when,  after  the  section 
of  the  neck,  each  ovoid  is  extracted  slowly  by  accommodating  it  to 
the  genital  passage. 

By  crushing — if  the  bones  are  broken,  to  lessen  the  resistance 
opposing  the  passage  of  the  child. 

Finally,  by  morcellement — when  the  body  of  the  foetus  is  extracted 
piece  by  piece. 

These  different  modes  of  reduction  are  often  combined  under  the 
action  of  one  apparatus. 

Numerous  instruments  have  been  proposed  for  the  execution  of 


424 


Embryotomy. 


these  manceuvers,  but  at  the  present  clay  those  most  in  use  are  the 
cephalotribe,  the  cranioclast  and  the  scissors. 

Let  us  study  successively  the  cephalic  and  the  corniic  embry- 
otomies. 

I.  Cephalic  embryotomy. — Cephalic  embryotomy  is  composed,  as 
has  been  indicated,  of  two  successive  operations  :  eviseration,  which 
necessitates  perf oration  of  the  cranium,  and  reduction. 

Among  the  numerous  visceral  embryotomies  or  perforators  that 
devised  by  Blot  is  the  best  (Fig.  513). 


FlG.  513. — Blot's  perforator. 


Fig.  514. — Lusk's  cephalotribe. 


The  cephalic  embryotomies  par  excellence  are  the  cranial  forceps, 
of  which  there  are  three  varieties:  The  intra-cranial  forceps,  in 
which  the  two  jaws,  introduced  through  the  perforation,  grasp  the 
base  of  the  cranium.  The  extra-cranial  forceps,  or  the  cephalo- 
tribe (Fig.  514),  in  which  the  two  jaws  arc  applied  to  the  periphery 
of  the  skull.     The  mixed  variety  of  forceps,  or  the  cranioclast  (Fig. 


Embryotomy. 


125 


515  and  516),  in  which  one  extremity  is  applied  in  the  cranium  the 
other  on  the  periphery. 
The  intra-oranial  forceps  is  bui  Little  used. 


Fig.  515. — Rraun's  cranioclast. 


Fig.  516. — Simpson's  cranioclast. 


The  cranioclast,  however,  has  an  extended  employment  in  various 
models.  The  plain  or  the  male  blade  is  introduced  into  the  cranium 
through  a  perforation  previously  made  and  the  fenestrated  branch, 
or  female  blade,  is  applied  on  the  periphery,  preferably  on  the  face. 

The  cephalotribe  is  only  a  strong  forceps  furnished  with  a  pressure 
screw  for  crushing.  One  of  the  best  models  is  that  of  M.  Bailly 
(Fig.  517).  After  the  perforation  of  the  cranium  it  is  applied  like 
the  forceps  and  the  head  is  crushed  to  the  extent  necessary  to 
permit  extraction. 

In  1884  Tarnier  modified  this  instrument,  giving  it  the  name  of 


426 


Embryotomy. 


basiotribe  (Fig.  518).  Later,  Bar  perfected  it  by  some  modifi- 
cations (Fig.  519).  The  basiotribe  is  composed  of  a  central  branch 
which  serves  as  a  perforator  and  of  two  lateral  branches  recalling 
those  of  the  cephalotribe.  The  operation  is  commenced  by  the 
introduction  of  the  perforating  branch  and  then  the  two  lateral 
blades  are  placed  and  the  crushing  is  successively  executed  with 
each  one  of  them. 


Fig.  517. — Bailly's  cephalotribe. 

Combined  forceps. — Combined  cephalic,  embryotomy. — The  cephalo- 
tribe constitutes  an  excellent  crushing  instrument.  On  the  other 
hand,  the  cranioclast  has  no  rival  so  far  as  solidity  is  concerned. 
These  two  instruments  are  then  indispensable  to  the  accoucheur. 
But  by  adding  a  third  branch  to  the-cephalotribe  I  have  designed  an 
instrument  which  may  be  employed  as  a  cranioclast  at  need,  and 
which  by  the  addition  of  this  third  branch  affords  all  the  services 
of  the  cephalotribe  or  of  the  basiotribe.  To  practice  cephalic 
embryotomy  with  this  instrument  we  proceed  as  follows :  The 
woman  being  anesthetized  and  placed  in  the  obstetrical  position, 
an  assistant  is  instructed  to  maintain  the  head  firmly  by  placing 


Embryotomy. 


127 


one  hand  on  each  side  of  the  hypogastriam.  ( raiding  it  on  the  left 
hand,  the  perforatoi  is  introduced  and  by  a  gimlei  it  is  sunk  into 
tin-  mosl  accessible  pari  of  the  cephalic  ovoid.  When  this  branch 
has  penetrated  the  cranium  it  is  pushed  in  different  directions  to 
dissociate  the  cerebral  Bubstance.    The  point  of  the  instrument  is 


Fig.  518. — Tarnier's  basiotribe. 


Fig.  519. — Bar's  cephalotribe. 


directed  as  much  as  possible  toward  the  occipital  foramen.  An 
assistant  is  charged  with  maintaining  this  branch  supported  on  the 
base  of  the  skull;  the  curve  of  the  instrument  (marked  on  the 
handle)  is  turned  toward  the  left  side,  that  is,  toward  the  blade  that 
is  next  applied.  The  left  branch  is  then  introduced  and  applied 
like  the  blade  of  the  forceps  on  the  fcetal  head.  When  this  is  ac- 
complished, the  1 'ranch  will  be  maintained  by  a  hook  at  the  handle. 
Thus  applied  1  Figs.  523, 524, 525)  the  combined  cephalic  embryotome 
is  only  an  ordinary  cranioclast  and  can  be  employed  as  such  if  its 
action  is  judged  sufficient.  But  if  it  is  deemed  necessary  to  com- 
plete the  crushing,  the  right  blade  is  applied  like  the  right  blade  of 
the  forceps  and  articulated.  Then  crushing  can  be  performed  by  the 


428 


Embryotomy. 


use  of  the  screw.  As  soon  as  this  is  completed  the  right  branch, 
like  the  left  branch,  as  we  have  already  seen,  is  held  by  a  hook  (Fig. 
52G)  so  that  the  pressure  screw  can  be  removed  and  extraction  per- 
formed. 


*        9 


mmimn 


Fig.  520. — Combined 
cephalic  embryotome. 


Fig.  521. — Perforation 
of  the  cranium. 


Fig.  522. — Application  of 
the  left  blade. 


II.  Cormic  embryotomy. — As  for  the  cephalic  ovoid,  we  are  here  in 
the  presence  of  two  distinct  operations,  evisceration  and  reduction. 

For  cormic  embryotomy  there  are  numerous  instruments,  but 
among  these  Dubois'  scissors  (Fig.  527)  is  sufficient  to  perform  all 
the  varieties  of  cormic  embryotomy,  and  on  this  subject  I  shall  be 
confined  to  indicating  their  employment  in : 


Evisceration. 

Decollation. 

Rachitomy. 

Melotomy. 

Morcellement. 


1.  Evisceration  {presentation  of  the  abdomen). — The  left  hand  being 
introduced  as  far  as  the  foetal  part  which  presents,  by  the  use  of 


Embryotomy. 


429 


the  scissors  guided  on  this  hand  the  abdominal  wall  is  opened  ;in<l 
through  this  opening,  enlarged  by  the  lingers,  the  abdominal  and 
thoracic  organs  are  torn  out  so  as  to  empty  these  cavities  of  their 
contents.  This  evacuation  generally  permits  termination  of  the 
extraction  by  internal  podalic  version  without  difficulty. 


Fig.  523. — First  crushing. 


Fig.  524. — Application 
of  the  right  blade. 


Fig.  525. — Second  crushing. 
Instrument  applied. 


Fig.  526. — Braun's  decapitating  hook. 


430 


Embryotomy. 


'2.  Decollation  {presentation  of  the  thorax). — The  foetus  presenting 
by  the  thorax  and  version  becoming  impossible,  it  is  necessary  in 
order  to  terminate  the  accouchement  to  decapitate  the  foetus,  so  as 
to  extract  successively  the  trunk  acd  then  the   head.     For   this 


Fig.  527. — Dubois'  scisors  (modified  by  Pinard). 


FlG.  528.— Section  of  the  neck,  with  Dubois'  scisors. 

section  a  hand,  preferably  the  left,  is  introduced  to  grasp  the  neck 
and  draw  it  down  as  much  as  possible.  The  neck  being  thus  held, 
the  scissors  are  used  with  the  free  hand  and  the  head  severed  by 
small  cuts  (Fig.  528).     As  soon  as  the  section  is  completed,  and 


Embryotomy. 


i:;i 


oare  tiaa  been  taken  to  tear  Loose  the  remaining  sofi  parts,  one  ol 
the  arms  is  seized  and  the  cormic  ovoid  extracted  (Fig.  529).    To 


S.  ti 


■■>•:  f$L 


Fig.  529.— Extraction  of  the  cormic  ovoid. 


Fig.  530.— Extraction  of  the  cephalic  ovoid. 


432  Hysterotomy. — Cesarean  Section. 

extract  the  head,  which  remains  alone  in  the  genital  organs,  a 
finger  is  hooked  on  to  the  inferior  maxillary  through  the  mouth  and 
this  generally  serves  for  extraction  (Fig.  530) ;  if  not,  the  forceps 
are  used,  or  even,  if  reduction  is  necessary,  the  cephalic  embry- 
otome. 

3.  Rachitomy. — If  section  of  the  spinal  column  is  necessary  it  is 
accomplished  by  the  scissors  guided  by  a  hand  introduced  into  the 
genital  organs. 

4.  Melotomy. — Section  of  the  limbs,  when  necessary,  may  also  be 
made  with  Dubois'  scissors  guided  to  the  parts  to  be  divided  by  a 
hand  in  the  genital  passage. 

5.  Morcellement  consists  in  extracting  the  foetus  in  fragments. 
Dubois'  scissors  will  permit  this  detachment  in  portions. 


CHAPTER  XXXIV. 


HYSTEROTOMY.— CiESARIAN   SECTION. 

Hysterotomy,  or  the  Caesarian  operation,  consists  in  opening  the 
abdominal  and  uterine  walls  with  a  knife,  in  extracting  the  fcetus 
and  its  appendages  through  this  artificial  passage,  and  subsequent 
closing  of  the  abdomiual  wall  and  the  uterine  wound  by  sutures. 
Under  the  impulse  given  to  classic  hysterotomy  by  Sanger's  modi- 
fications Caesarian  section,  as  practiced  at  the  present  time,  gives 
results  much  superior  to  Porro's  operation.  In  the  ulterior  course 
of  this  description,  then,  I  shall  have  exclusively  in  view  classic 
hysterotomy,  only  incidentally  speaking  of  Porro's  operation. 

Preliminary  precautions. 

Moment  to  choose  for  the  operation. — It  seems  preferable  not  to 
wait  for  the  beginning  of  labor,  but  to  choose  the  last  days  of  preg- 
nancy before  the  appearance  of  the  pains.  In  this  way  all  the 
preparations  may  be  made  with  great  care  and  all  the  conditLms 
favorable  to  success  are  more  easily  united.  It  has  been  objected 
that  this  period  exposes  to  uterine  inertia,  but  this  objection  has 
not  been  proven  and  is  not  probable,  for  the  uterus  is  equally 
retractile  at  all  the  periods  of  the  puerperal  state. 

Xeccssary  instruments. — Ordinary  and  probe-pointed  knives,  dis- 
secting forceps,  a  dozen  haemostatic  forceps,  scissors,  Pieverdin's 
needle,  ordinary  needles  and  a  needle-holder,  silk  thread  of  two 
sizes,  hot  and  cold  antiseptic  solutions,  soap,  brush  and  razor  for 


Hysterotomy. — <  'cesarean  s,  ction. 

the  antisepsis  of  the  abdominal  wall,  ether,  a  dozen  antiseptic 
towels,  iodoform  gauze  in  Btrips  and  in  Bquares,  iodoform  in 
powder,  a  dozen  Bponges,  Bis  large  and  six  Bmall,  antiseptic  cotton, 
bandage,  obstetrical  forceps,  solution  of  ergotine  and  b  hypodermic 
Byringe. 

Ana  Bthesia  Bhould  he  made  with  chloroform. 

Assistants. — One  for  anaasthesia,  one  for  the  ahdomen,  one  for  the 
instruments  and  one  to  receive  the  child.  Two  others  for  emer- 
gencies. 

I  'arious  precautions. — Vulvo-vaginal  antisepsis  for  four  or  five  days 
before  the  operation.  One  or  two  baths  during  the  two  or  three 
days  previous  to  the  intervention.  Laxative  the  evening  before  the 
operation. 

Before  operating,  while  anaesthesia  is  being  made,  catheterism  of 
the  bladder.  Shave  all  the  subumbilical  region,  terminating  this 
by  washing  with  ether.  Wrap  up  the  lower  limbs  and  the  thorax 
to  prevent  chilling. 

Operation. — The  operation  is  performed  in  three  stages  : 

a.  Penetration  to  the  ovum. 

1.  Incision  of  the  abdominal  wall. 

2.  Incision  of  the  uterine  wall. 

b.  Extraction  of  the  ovum. 

3.  Extraction  of  the  child. 

4.  Extraction  of  the  appendages. 

c.  Sutures. 

5.  Sutures  of  the  uterus. 

6.  Sutures  of  the  abdominal  wall. 

1.  Incision  of  the  abdominal  wall. —  Incision  of  fifteen  centimetres 
on  the  median  line,  starting  four  fingers'  breadth  above  the  symphy- 
sis pubis  and  passing  around  the  umbilicus,  preferably  to  the  left 
to  avoid  the  suspensory  ligament  of  the  liver  (Fig.  531). 

•1.  Incision  of  the  uterine  wall.  —  The  uterus  being  laid  bare,  it  is 
brought  up  and  maintained  in  the  median  line ;  the  assistant  is 
directed  to  apply  the  abdominal  wall  firmly  on  the  organ  to  avoid 
the  escape  of  the  liquor  arnnii  into  the  peritoneal  cavity.  On  the 
median  line,  parallel  to  the  abdominal  incision,  the  uterus  is 
punctured  with  the  knife  at  a  point  where  palpation  cannot  detect 
any  foetal  part.  Into  the  button-hole  thus  created,  tha  finger  is 
introduced  to  serve  as  a  guide  for  the  incision  of  the  uterine  wall. 

3.  Extraction  of  the  child  (Fig.  532). — At  the  opening  thus  created, 
through  which  the  liquor  amnii  escapes  in  abundance,  or  a  fatal 
part,  head,  breech,  or  intermediate  part  of  the  trunk  quickly 
presents.     Sometimes  the  retraction  and  the  contraction   of  the 


434  Hysterotomy . — C cesarean  Section. 

uterus  are  sufficiently  energetic  to  push  the  foetus  into  the  artificial 
opening.  It  is  then  sufficient  to  aid  this  exit.  If  this  does  not  occur 
extraction  is  performed,  either  by  the  aid  of  the  forceps  (if  the  head 
presents)  or  by  the  use  of  the  hand  (if  the  trunk  presents).  The 
cord  is  tied  and  cut  and  the  child  is  immediately  given  to  the  person 
who  is  to  receive  it. 


Fig.  531. — Caesarian  operation.     Incision  of  the  abdominal  wall. 


Fig.  532. — Caesarian  operation.     Extraction  of  the  child. 

4.  Extraction  of  the  appendages  (Fig.  533).  — The  right  hand  is 
passed  at  once  into  the  uterus  to  seize  the  appendages,  as  in  an 
artificial  delivery  of  the  appendages.  The  placenta  and  the  mem- 
branes are  brought  out  through  the  ntero-abdominal  opening. 


Hysteroton  vrean  Section. 


5,  Sutures  of  the  uterus  (Sanger).    -After  having  carefully  eleai 
all  the  internal  surface  of  the  uterus  and  assuring  the  permeability 

of  the  cervical  canal,  the  uterine  wall  is  closed   by  the   u-.-  of 

and  of  superficial  Buturea  (oi  Bilk). 


Fig.  533. — Caesarian  operation.     Extraction  of  the  appendages. 

The  deep  sutures  should  be  placed  at  one  centimetre  and  one- 
half  from  each  other,  not  including  the  uterine  mucosa  (Fig.  534), 
but  passing  at  some  millimetres  above  it  to  avoid  any  communication, 
by  the  intermediary  of  the  threads,  between  the  uterine  and  the 
peritoneal  cavities. 


Superficial  suture 
Deep  suture 

Peritonaeum. 


Uterine 

Muscle.  ^== 


Mucosa. 


Fig.  534. — Sutures  of  the  uterine 
wall,  view  of  a  section. 


Fig.  535. — The  same,  seen  from 
above  after  completion. 


The  superficial  sutures  should  be  placed  one-half  centimetre 
apart,  two  between  each  deep  suture  (Fig.  535).  It  is  important  to 
assure  coaptation  of  the  peritoneal  lips.  The  Buturea  are  placed  so 
that  the  free  edges  of  the  peritoneum  are  fixed  and  maintained  in 
the  wound  by  the  tension  of  the  stitches. 

6.  Sutures  of  tJ><-  <ih<h>inhi<d  watt.  —  Before  proceeding  to  these 
sutures,  it  is  necessary  to  make  the  toilet  of  the  peritoneum  by  the 
use  of  aseptic  sponges  to  collect  all  the  liquids  that  have  passed  into 


436 


Hysterotomy . — C cesarean  Section. 


the  serous  cavity.  The  deep  sutures,  placed  at  one  centimetre  and 
a  half  from  each  other,  should  comprise  the  free  edge  of  the  peri- 
tonaeum (Fig.  536).  The  superficial  stitches  are  placed  at  one-half 
centimetre  from  each  other  (two  between  each  deep  suture)  and  do 
not  require  any  special  precaution  (Fig.  537).  Drainage  is  useless. 
A  simple  dressing  of  iodoform  gauze,  maintained  by  a  bandage,  is 
adapted.  The  consecutive  treatment  is  analogous  to  that  after  a 
laparotomy. 


Peritonaeum. 


Fig.  536. — Sutures  of  the  abdominal 
wall,  view  of  a  section. 


Fig.  537. — The  same  seen  from 
above  after  completion. 


Porro's  operation  consists  in  removing  the  body  of  the  uterus. 
To  this  effect  the  body  of  the  uterus  being  brought  outside  the 
abdomen  it  is  transfixed  at  the  union  of  the  body  and  the  cervix  by 
two  metallic  pins.  x\bove  these  pins  is  slipped  a  loop  of  wire  to 
constrict  the  pedicle.  For  greater  security  it  is  better  to  place 
below  the  pins  a  second  wire-loop.  The  uterus  is  excised  at  two 
centimetres  above  the  constricting  wire  and  the  stump,  thus  consti- 
tuted is  fixed  in  the  abdominal  wound,  which  is  closed  as  completely 
as  possible  by  the  use  of  ordinary  sutures.  The  wire  loop,  the  pins 
and  the  ligatures  are  removed  at  the  end  of  a  time  which  will  vary 
with  the  rapidity  of  the  pedicle  and  of  the  wound. 

Porro's  operation  should  be  reserved  for  exceptionally  grave  cases 
and  those  where  putrefaction  of  the  ovum  in  the  uterine  cavity  or 
a  septic  process  causes  fear  that  the  uterus  may  be  affected  by 
septicaemia. 


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